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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Marl<e:F a P,�� 6oI�ZCo 6F4�74ro72 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY AME <br /> ,,ahs( cw -O aJ L <br /> SITE ADDRESS (�- �'r1..�C( t N . wvS+, 11 `,Vh�e Cfr �533(� <br /> pp <br /> �J? W-Yvx*;yam S(reet Number I Direction Streel Name CI ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1 _ �!(� [�.J'f 'L <br /> C�LKSTT S,re umber Y�O� Street Name <br /> Cin• STA E ZIP <br /> Q Cu.� <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> M11. ) Isiq <br /> • PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �^^r� CHECK If BILLING ADDRESS <br /> PHONE# T' <br /> BUSINESS NAME 1'cc�b",b� , S -)S5 7�i <br /> HOME or MAILING ADDRESS FAX# <br /> ISS N. ( ) <br /> CITY i '• \^CJ' `, STATE ZIP 7 / <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 /> I 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7I �(3ON k. <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmerp?oQpation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS prOW(I �- T <br /> my representative. /� �� #/(( C <br /> TYPE OF SERVICE REQUESTED: �OI "� �'h C*C,,� — E>c ,4 APR <br /> s <br /> COMMENTS: SAN JUIN <br /> OlN('iPN WGts ('I�Dvm2� �� <br /> ��Py��,,��,,��ac. pl"s avRl� 2(/t1'Dv%iv ��� q jRo ^CO NTy <br /> Owlet/ C,K�i no J119 4vi �f-e. HOF ARTM <br /> ACCEPTED BY: EMPLOYEE#: DATE: 4/Ie/(b <br /> ASSIGNED TO: e�M yLQ L;n Ptj EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CLL x92,3 PIF. 1� <br /> Fee Amount: 5es.OD Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: 7.7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />