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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pro erty FACILITY ID# SERVICE REQUEST# <br /> �61L [NG <br /> OWNER I OPERATOR V AV�1S -W GILL- CHECK if BILLING ADDRESSLLI' <br /> I ACIUTY NAME T2 U L(C W G <br /> SITEADDRES$ L [10'> L 1'f N2 U� 1 r) z31 <br /> Street Number Direction 1` Street Name city Zip Cod. <br /> H)Mi:or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> Cr' STATE ZIP <br /> PNONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICTLOC/AryyT.aION CODE <br /> ( ) O O , 'f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR TO W y S)IQ G N <br /> 1 II�� '� CHECK If BILLING ADDRESS <br /> BUSINESS NAME C—""Ti-')Z' c o� O ryY,up j- PHONE# Ext. <br /> 2'tJ�— b34 <br /> HOME or MAILING ADDRESS FAX# <br /> le JLt29sf l�lrcl• 3}e Imo (7Uz) C4_ :2- 'L <br /> CITY I-as STATE NU ZIP 8 � I3.K <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 bilkid to me or my business as identified on this form. <br /> I a:.-.o certu/that I h.,.ve prepared this application and that the work to be performed will be done in accordance with :.J SAN JOAQUIN <br /> ( COUNTY Ordina ie Codes,Standards,STATE and FEDERAL laws. ff <br /> APPLICANT'S SIGNATURE: J wwti �— DATrE:: /(( I�`(' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT IN Ge h S <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property Ionated at Le 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 to me or <br /> my representative. /per <br /> TYPE OF SERVICE REQUESTED: LI I�'C T <br /> COMMENT$: Ib (, O✓ <br /> / / N <br /> II I� �� u/xv ��1 t 7✓ ,�=-wy� y�q�fyO�oUrNc?QI <br /> �� yewy40' nA NAr�N <br /> 5q <br /> ACCEPTED BY: EE#: DATE <br /> x J <br /> ASSIGNED TO: TGl Oj 10 Lt EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed); SERvicECoDE: �� PIE: 2 U� <br /> Fee Amount: -�C)OO Pai 5-(.DaPayment Data <br /> Payment Type ���� Invoice# Che # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />