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a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> w e- - N �,W S �6 O7 9 of �- <br /> OWNER/OPERATOR <br /> CHECK If BILLING A DRE <br /> FACILITY NAME t-->�elr's <br /> SITE ADDRESS Z--IV5[L� <br /> Street Numb/er I Direction JL-J1 Street r/f'drf/"ew'� �`gyp(/ 'Cli��_ •! Zi Cod <br /> HOME 6-r MAILING ADDRESS (If Different from Site Address) K rN/ <br /> lJJ6Street Numbert.rdet Name <br /> CITY STAT zip <br /> q5-6 CP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION'# <br /> ( 4I)S '� p '00 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> IA <br /> �`,� .C� CHECK if BILLING ADDRESS <br /> BUST ESS N C/r' PH04#�^ EXT, <br /> 'Ch1 — <br /> HOME or MAILING ADDRESS FAX# <br /> S ( ) <br /> CITY I ,,�(n L �U J STAT zip `y/_ D <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property obusiness owner perator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH ourly 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 preparedthis agpLization and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, E FEDERAL laws. <br /> APPLICANT'S SIGNATURE: \7 DATE: <br /> PROPERTY/BUSINESS OWNER OPER R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ PA <br /> -11 <br /> If APPLICANT is 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 a�M1c <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess nforma <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pr I d jo8ne or O <br /> my representative. `Sgly v Z� <br /> TYPE OF SERVICE REQUESTED: (_) �/� .��k— yEA("'WON�NCOU <br /> COMMENTS: 'qR <br /> If-S-0 S F- co ��� l d5 h4 l ( "0/ 3)` ✓P-�-t•r MEN <br /> wlhde)w . <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO. ` Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z PIE: U� <br /> Fee Amount: [+5/_ Amount Paid / v� Payment Date <br /> l0 & G <br /> Payment Type CK J Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />