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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7/261C*/", <br /> OWNER/OPERATOR <br /> S CA t't tJ CCk rL •!`�' R S S �f t/ CHECK If BILLING ADDRESS <br /> — <br /> FACILITY NAME <br /> IT ADDREw /� ,q W eA Cr U ��•2l7 <br /> Street Number Direction Sy—et Name city ZIn Code <br /> HOME Or MAILING ADDRESS (If Different fro Site Addrgss <br /> Suh v u�l a £ res s AGI 1Ca�Z q k I4 h G UW(1 K l�� <br /> Street Number streetName <br /> CITY hI)f STATE ZIP <br /> 95-Z <br /> 5Z 3 <br /> PHONE#f E.T. APN# LAND USE APPLICATION# Ic <br /> ��y) �F�l, r3� m(3— o <br /> PHONE 42 EU. BOIS DISTRICT LOCATIOCODE <br /> ( ) DO� 11 <br /> CONTRACTOR/ SER CE REQUESTOR <br /> REQUESTOR N // / <br /> {X 400 eG .CHECK If BILLINGADDRESSA <br /> LLLGGG^ ///�'1.."'___P111 H00�'I# EXT. <br /> BUSINESS NAME Ltli4 // � 1//- G <br /> HOME or MAILING ADDS C` FAX# d l <br /> . o .4�oy— (Z3cj ( ) _ <br /> CITY ,tiles-G•" STATE ZIP <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,SrnrE a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATF} >- -f�Y-- Q <br /> PROPERTY/BUSINESS OWNER P OR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT Is not the BILLIN ARTY,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 /> t0 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 REQUESTED: <br /> COMMENTS: ZIlU(`/ 11q14' <br /> /C4' / RECOtlGD <br /> DEC, o y zor? <br /> q, 1 S I�VItIA C7' EINVIRONMEJOAQUIN �AI <br /> ACCEPT BY: Mwti�fQ, (� EMPLOYEE#: HEALTH DATE: <br /> ASSIGNED TO: LJUr,,\ EMPLOYEE#: DATE: l( L-S-t-T <br /> Date Service Complete (if already completed): SERVICE CODE: PIE:,-,7b67,-- <br /> Qv <br /> Fee Amount: Amount Paid ��� — Payment Date 1) . <br /> Payment Type C_ Invoice# Check# - Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />