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i <br /> SAN JOAQU COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V*0002 fbo`NDc-�{ <br /> OWNER I OPERATORf� <br /> � j.� C�eeye✓ 1K �t A17� )K G7GU1,g CHECK If BILLING ADDRESS <br /> I <br /> FACILITY NAME <br /> I" SITE ADDRESS <br /> Street Number Direction Street Name cityZI Cade <br /> II <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> j CITY STATE Zip <br /> II PHONE#I ExT. APN# LAND USE APPLICATION# <br /> t27) 57-7. 3 2S� 24. 24 40Z 5- z- <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> i REQUESTOR `� SrRn-cam <br /> j/V-"n CHECK If BILLING ADDRESS <br /> t BUSINESS NAMEPHONE# ExT. <br /> j'/�cJ �rfoGi —T Zoe 523. g 3'z3 2�f <br /> t <br /> HOME or MAILING ADDRESS2�3 7 r e�7G ��l V6 " 40VFAx# S29 '7,O 4- <br />+ CITY /e77C�i r 1 !� f S.3 5--r 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 ide '' d on this farm. <br /> i I also certify that E have prepared this lIcation and That the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standa STATE and FE RAL la <br /> APPLICANT'S SIGNATURE' DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR 1 MANAGE OTHER AUTHORIZED AGENT 0 <br /> If APPLICANT is not the BILLING PARTY.pro0 authorization to sign is required Title <br /> AU T HORIZATIu1,41 TO RELEASE 191411FORMATION: 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 /> to 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. WMENT <br /> TYPE OF SERVICE REQUESTED: 0 1 Q,�') �/1 L�C�� <br /> RECEIVIED <br /> COMMENTS: <br /> JAN 14 Hit') <br /> SAN JOAQUIN COUNTY <br /> ENViROMENTAL <br /> K-L HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE DATE: o! <br /> ASSIGNED TO: L!"-)� EMPLOYEE#: DATE: 0 0411 V, <br /> Date Service Completed (if already completed): SERVICE CODE: (`r P 1 E: �bT <br /> Fee Amount: D-M) Amount Paid 3 0. d (� Payment Date f <br /> Payment Type �[� Invoice# Check# 12 0'3 Received By: /) <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07117,'08 <br />