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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -I EC G u 5fzo� 73$ <br /> OWVEhi OPEKATOR <br /> CHECK if BILLING ADDRESS <br /> F, .IIITYNAME <br /> SITE ADDRESS �� rt`E:ti�N C4fLt 9S23I <br /> G �._ Street Numb¢r Dire ti¢o— G . I�O ¢¢t Name city Zip Code <br /> HUM,E Or i4AII ADDP'$$ -f Ldferc, rr n, ae Adciressj <br /> 6-5 Street Number Str+et Name <br /> r:ITY T STATE. (Z-A ZIP Q <br /> PHONE All 1- Ev. APN# LAND USE APPLICATION# <br /> 'HONE#2 E■T BOS DISTRICT LOCATIO E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V`///��� <br /> / ..,r L- 1 l— CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> HOME OrSr1AILING ADDRESS FAX# <br /> 5 23 `A -154 <br /> CITY F—iZ FA-CK CA <br /> STATE „ra^'lZIP 9S '}Z <br /> BILLING AACCKNOWLEUGENIENT. I,, th , undersigned property or business owner, operator or authorized agent of same, <br /> acknowledg= that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will Ile oilled to me Or my b tsiness as identifie on this form. <br /> I also certify that I have prepared this al-ilicatio,-, and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE;: RAt law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ '• _ <br /> If,-iPPLICANT is not nIR Brun=PARTY proof of authorization to sign is required Title <br /> .AUTHORIZATION TO RELEASE INFORMATION: , hen applicable. I, the owner or operator of the property located at the above <br /> site address, here-hy sut[�orize the release of anv a ld all r(sults, geL;echnical data and/dr environmental/site assessment information <br /> to .: ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL DE?P 4TMPNT as suon as it is available and at the same time ii is provided to me or <br /> my represent: Ive <br /> Y?r OF SERVICE REQUESTED: \�i 1" �GrNI ��-\e PAYMENT <br /> ;MNIENrs:� S <br /> CM p ,,,� nn/+_Q GGhI <br /> 11 15/ � >��L 0 V-I& <br /> f � NOV 0 'L 2Ji7 <br /> �S SAN V AQUIN ROMENTOALN <br /> i <br /> HEALTH DFIPAFITNIFNT <br /> ACCEPTED BY:- <br /> EMPLOYEE#: <br /> ASSIGNED TO: i ��Sj y�OS EMPLOYEE#: DATE: <br /> Date Ser,ice Completed (if already completed): SERVICE CODE: a;�:�r7 - - <br /> FeaAmount: 2,(0 C) f7 Amount Paid Gam, Payment Date t( oZ <br /> Payment Type G Invoice# Check# 10(9 C2 Received By: <br /> EHD 48-02-025 ,� rq /y,�b SR FORM(Golden Rod) <br /> 07/17/08 (l fvl V <br />