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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WLAV"� vmCew� S{ U1So0�1 <br /> OWNER(RPERATOR ` ((( <br /> U 4 L p 'wt CO <br /> FACILITY NArA <br /> ME CHECK If BILLING ADDRESS® <br /> �O1 ,v <br /> SITE ADDRESS <br /> 15-To <br /> Qe2ir A� S'1>K " 96dig7 <br /> 1�/• Street Number I Direction Street Name CIN Zlo C.d. <br /> HQME or FAILING D LE/�S�1.S pit Different from Site Address) <br /> 0. (S - ` Street Number �� Street Name -T <br /> CITY 1 }ti c6.1 rTA✓t— zip <br /> PHONE#1 EXT. APN# LAND l7 E APPLI,.aTION# <br /> (ail)- <br /> PHONE#2T BOS DISTRICT Ln CATION CODE <br /> (D-*) 609_ -tool _ <br /> CONTRACTOR/ SERVICE FEQUESTOR <br /> REQUESTOR lei. f`1/ 1 If �wy/4 <br /> V CHECK If BILLING ADDRESS® <br /> BUSINESS NAMEw � PHONEEXT. <br /> vkk); <br /> Lt.-I5 -38G� <br /> HOME or AILING ADDRESS FAX# <br /> :r-0, I (a ) q5(- X144 <br /> CITY h S&AIE zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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,S E d FEDERAL laws. / op,, <br /> APPLICANT'S SIGNATURE: y DATE:X 6l V/1 G <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 17 OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REC:U1ESTED: � PAYMENT <br /> l <br /> COMMENTS: a -C'tll. -2t 31 Lf. <br /> 1714?0''II noel- r t y <br /> bO <br /> fy <br /> _ HEAI:111 DEPARTMENT <br /> ACCEt'TED BY: EMPLOYEE#; DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date S,-,vice Completed (if already completed): SERVICE CODE: <br /> Fee Amount: u` Amount Paid G S� •d Payment Date GZZ <br /> 6 <br /> Payment Type Invoice# Check# (o I a Received y: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />