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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> RREQUEST# <br /> !>r;^��C WL'fv Q•lrr I-Inr'1 Lis '�� ��� `�$� <br /> OWNER/OPERATOR _ } <br /> � ( I �, fV / CHECK If BILLING ADDRESS <br /> FACILITY NAME I V M �/ 11 vv/ <br /> SITE ADDRESS t-41/- L4 y,JA`-( IZ Lobi d.��j zd-O <br /> �1 -7t01 SlreetNumber Direction I Street Name _ cit Zi Code <br /> HOME Or ( yING ADORES tlf Different from Site dress) <br /> l (0 4t <br /> D Q Slreet Number Street Name <br /> CITY _ STATE ZIP <br /> PHONE#t ExT' APN# LAND USE APPLICATION# <br /> 3�g - <br /> ' M /-4- - (mss <br /> P ON #2 ExT3 6:71 ' BOS DISTRICT LOCATI11 <br /> ON CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS L�E] <br /> I <br /> BUSINESS NAME4.0 <br /> J�v l J� I 1 PHONE# ExT. <br /> -1). �, J�IL10 LA-LV x"141 209 -* —O 1 CO 9 <br /> HOME Or MAILING ADDRESS FAx# <br /> T•O. 1B.0)C +35- <br /> CITY La ra C STATE GP ZIPOI S2* / <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 wii!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 accord21--e with all SA:. IoAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: DATE: 17 — 0¢ .- I S <br /> p <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT lc.l Lr�ij 10 S V r <br /> It APPLICANT Is not the BILLING PARTY proof of authorization t0 sign Is required Title <br /> AUTHORf_ATION TO RELEASE INFORMA`I ION: 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 COUN rY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pi ovided to Lie oI <br /> my representative. _ <br /> TYPE OF SERVICE REQUESTED: G{�Y✓d'1 r�l�i(_1 IU�I <br /> COMMENrS: J�I�-I�� RECEIVE <br /> DEC 0 4 201 <br /> �gdnp;.l� HA ENV ROMEry OU N <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 { 1>•HTIy '� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SL3�� <br /> Fee Amount: ,� Amount Paid 2&O . D U Payment Date I Z/I+ lu <br /> Payment Type ✓ Invoice# Check# l0l�7 J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />