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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />_ <br />5�2 (yo � S �?S <br />OWNER / OPERATOR <br />PHONE # <br />Z -N <br />EXT. <br />cl.- �-t 7 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br /># <br />(16' q) <br />-7- (o <br />CITY t� f 1,011 WO C'` <br />SITE ADDRESS <br />ZIP c�� (Dog -373 Li <br />TA <br />s f o c'K� n <br />� � 2�1 j <br />Street Number <br />Dfon <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1 <br />S _ <br />_ i V Ck I e– C-0 <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />wee <br />STATE 71c <br />r4 `il (o i)c; <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />41S) . �j� J t�Q <br />PHONE #2 EXT. <br />GIG U <br />BOS DISTRICTLOCATION <br />CODE <br />(Cd, b) C)24 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR __�,11 <br />G'em Q rtX I n o H u Q -Y- 11 cA <br />A Y <br />CHECK If BILLING ADDRESS In <br />BUSINESS NAME <br />iV 1 Fri cG <br />PHONE # <br />Z -N <br />EXT. <br />cl.- �-t 7 <br />HOME or MAILING ADDRESSFAX <br />c&, - - <br /># <br />(16' q) <br />-7- (o <br />CITY t� f 1,011 WO C'` <br />STATE CA <br />ZIP c�� (Dog -373 Li <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />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, ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:DATE: 10'Y <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR I 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 information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: ' U O Q <br />A Y <br />COMMENTS:r00A co&;}' 1 '� ^ <br />V—PD <br />SA <br />KQU/N <br />& C <br />hpgt 1110tvu N SNIy <br />A I <br />ACCEPTED BY: (,�Oa no <br />EMPLOYEE M <br />DATE: <br />TA <br />ASSIGNED TO: FeAva <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0(Q / PIE: <br />Fee Amount: I -- <br />Amount Paid <br />S _ <br />Payment Date j /4 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />