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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LUOIKeOCA L4 Coc;nn <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> .n EI <br /> FAC TV NAME LreY <br /> SITE <br /> //rADDRESS C _I ( DorcLdp 5-• 5�CL-4c)n g5206 <br /> I Ll 5• Street Number Direction C sheet Name J CI Iv ZI Code <br /> HOME Or MAILING ADDRE S (If Different from Site Address) <br /> f Q Street Number 5helr l da rk Street Name 11.I <br /> CIN STATE ZIP ^ <br /> cK o l <br /> PHONE#1 Ext. APN# LAND'USE APPLICATION# <br /> ( —6P <br /> PHONE#24 EKT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> Io D. <br /> ,� „a i CHECK If BILLING ADDRESS <br /> tyeaqcBUSINESS AM �`' ` q PHONE# f EM' <br /> HOME or MAILING ADD SS FAX# 'O <br /> ( ) <br /> CITY + c ( STATE ZIP <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 /> 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: Z E 0 6 l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It Is available and at the same tinPJ� me or <br /> my representative. rr <br /> TYPE OF SERVICE REQUESTED: T C_(" FEBCOMMENTS: B 0 6 2098 <br /> ...) SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: V EMPLOYEE M DATE: 2—I L. <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paidf s a- — Payment Date 6. �I <br /> Payment Type Invoice# Check# - ;y: <br /> EHD 48-02-025 W(Golden Rod) <br /> 07/17/08 <br />