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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ,Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 I�aaJ '�2 <br /> OWNER/OPERATOR — <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME YVh1 - <br /> SITEADDRESS 1t�,.��/ (/aC V <br /> `8treAumber Direction Streel Name VMC)/ <br /> � Gi _/ZSf Cotle <br /> HOME or MAILING ADDRESS (If Different from Site LAddress) 1 /7 /'.1// <br /> 4/ Street Number • Street Nelme�—I <br /> CITY STATE ZIP /7 <br /> PHONE)'I / I ET' APN# I -Lo0 c5--�5 FBO <br /> ND USE APPLICATION# <br /> PHONE#2 EXT. LII S DISTRICT LOCATION CODE <br /> ( ) O dNC <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR —],jr�j /' <br /> ' I C I!— CHECK If BILLING ADDRESS <br /> BUSINESSNAME �„ PHONE# <br /> U � <br /> HOME Or MAILING ADDRESS 40�6 „ /l_� ^� (A%# ) <br /> CITY c C!'J1/TI STATE ZIP <br /> Jia <br /> ILLING ACKNO LEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> cknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> ctivity will be billed to me or my business as identified on this form. <br /> I <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 <br /> 9/FEDERAL laws. J D <br /> APPLICANT'S SIGNATURE: DATE: I`Q / �O <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment jialprimation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same tl� %*Wtto me or <br /> my representative. f�'f/"1�� <br /> TYPE OF SERVICE REQUESTED: '- - O <br /> COMMENTS: , JA <br /> &An 0 LOVIe --:) p SANJOAQUIN COUNT( <br /> _I WRONMENTAL <br /> HFAI-TH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CIO PIE: )�¢6 <br /> Fee Amount: 20 <br /> 0 Amount Paid 5-'1 Payment Date <br /> Payment Type I I� Invoice# Check# 5 ReceivedBy: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />