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F <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL_HEALTH DEPARTMENT <br /> I SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> 13 <br /> r /7 AJ <br /> 7-FFn, In0AIf?^��A / <br /> FACILITY NAME C G CHECK If BILLING ADDRESS <br /> 1C <br /> R c GArrllC C�nrT� <br /> SITE ADDRESSIOD 7 IZ,4 �� O� <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 11.2-17 q /A R d/� •SdA <br /> Street Numher Street Name <br /> CITY IRA <br /> C STATE CA zip <br /> PH NE#t EXT. APN# LAND USE APPLICATION# <br /> �) X07 - �9s o2 /a -190 - /,2 R -aB -Ooda <br /> PHONE#2 EXT. BOS DISTRICT LOGATJQN CODE <br /> ( ) Is— C� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUES70R +/�}n ,t / <br /> Jr;//V CHECK if BILLING ADDRESS <br /> BUSINESS NAME � cI�T PHONE# Exr. <br /> X 5/v E- C'a�SGC GT/tel /46 8- 93 <br /> HOME Or MAILING ADDRESS FAX# <br /> r' • - O 714 ( ) <br /> CITY �Q GOC k STATE /'!1 zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, of ppeer\ator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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, TE and F> laws. / q <br /> APPLICANT'S SIGNATURE: DATES0 <br /> :/ �/— Q' / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ElTHER AUTHORIZED AGENT LfS <br /> If APPLICANT is not the BILLING PARTY proof of aut toriZation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:/V T/2A TF 4OA D/A/ SD/L Su/TA-P/L / L 01 ES �I//E W <br /> COMMENTS:! 4/1 ��"'� iL_-�,�p-� , _+����� PAYMENT <br /> S a <br /> -7 �` RECEiVED <br /> y O JUN 3 Q 2009 <br /> SAN JOAHQONSME COUNTY NTY <br /> AccE BY: O(_L\)C( 0!-A EMPLOYEE#: 3 Z <br /> ASSIGNED TO: f©�� p S EMPLOYEE#: *0 VLS DATE: C' 3S ©t/`� <br /> Date Service Completed (if already completed): SERVICE CODE: 5 Z� PIE: 2 2— <br /> Fee <br /> Fee Amount: S-Z�d"7D Amount Paid [ 2—C Payment Date 3 <br /> Payment Type V' Invoice# ✓Check# 3b y Received By: <br /> EHDREV SED 11117/2003 <br /> 111 SR FORM(Golden Rod) <br /> REVISED 1 1 11 712 00 3 <br />