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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE R <br /> Type of Business or PropertyEQUEST# <br /> Fou- S6V-2y1 C-& xfgT 1 o'9'gf4 _ . UD --75W5 <br /> OWNER 1'OPERATOR CHECK if S.LL ING Aqr_�Rtss <br /> FACILITY NAME <br /> SITE ADDRESS r 7J I vVV- 1-0 it f S67 /-1 Va MA7`r g 33�o <br /> __ Rp__ Slreet Number Qiractirn ,_ ,_�,:itreet Name. <br /> HOME Or tltvr ADDRESS (if Different from Site Address) <br /> StreStreet_N_ame ets ii•:,ir y'_.:r <br /> C€f Y STATE zip <br /> PHC.P1E#1 ExT. APN !-,Ali .USE APPLic"',ION# <br /> i PHONL ti2 EXT. SCIS Dis',:24CT LOCATION r ODE <br /> I <br /> CONTRACTOR/ SERVICE REO UFSTi r)r,.. ._......�... <br /> 1 RF:ouE:TOR /V\ r y ` 14 <br /> ( LJ1 CHECK if BILLINr ADDRESS <br /> BUSINESS NAME • f!col �"rV lit f�`K1v(� P # 00 Z()()2 ExT. <br /> t HOME Or MAILING ADDRESS FAX# <br /> 2g 3 w Ldp �r� �--✓� ( ) <br /> CITY STATE ZIP G`S— <br /> B{LL{NG AJCi{YN'OrlMI_EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> I acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form, <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. b <br /> APPLIDANT'S SIGNATURE: DATE: p - I L <br /> PROPERTY I BUSINESS OWNER OPERATOR/MA AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ti rI e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, thn owner or operator of the property located at the abc:re <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avalable and at the same time it.S provided to me or <br /> my representative. �3 �a <br /> TYPE OF SERVICE REQUESTED: p {� <br /> COMMENTS: rn JER•9 p 20r� <br /> �G req e C) 4 w n�� SA'V JOAQUI e U! <br /> QUf <br /> kEa4rN o°aR MENS' <br /> ACCEPTED BY: EMPLOYEE#: DAT.: <br /> ASSIGAlEO TO: EMPLOYEE#: DATE: <br /> in hQAI�2 <br /> Date Semrice Completed (if already completed): I! SERVICE COP=: PIE, <br /> _ ��__ <br /> Fee Amount: V AU Amount Pal ,��� (� Payment Date <br /> Payment Type Invoice# Check# Recei�d By: 1 <br /> � � I <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />