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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property y— /� IIl FACILITYID 4t E VICE REQUEST,'.' <br /> GO/h�l� CJ/� Z II AV l/�.' <br /> (OWNER./OPERATOR <br /> /� J1 /� ,n� Me OM0 Al J ��/I y 1 ,/ ,/ CHECK If BILLING ADDRESS <br /> F/IcII I I Y NAME C/'Cn/1,/o(IJ /pC fi [J V 'J �l/�hf <br /> AQ7 L Lyq -7-a Fools OeA <br /> SITE ADDRESS + (l /l /�14Ae)A 4 ;S 7;n--k`Ta!✓ [�1 <br /> Street IJumber Direction Streut Name Cit Zi-i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number I C l�-t Street Name G I <br /> r <br /> CITY114AIITI /)- J /J 01 ZIP �S J�� <br /> PIIOIiE'?1 c /'7 EXT. APN# LAND USE APPLICATIO14# <br /> (?09 )GA1 I -8'1 g � <br /> PIi01'E EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERN710E REQUESTOR � <br /> EC]UESTOR / ) � 7-H >/--AM/, T ' / /t ��� �l,�'nA'V HECCK If BIL�G ADDRESS <br /> 7 // �//`/meg�"Jl U // /7 <br /> BUSINESS NAME I PHONE V�EYT.1 /V 1-4 reG,sQA <br /> HOME or MAILIIJG ADDRESS <br /> FAX 6' � <br /> CITY Tt r/�/v 1l7/ STATE L 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 EIl:�IRot1UE11TAL H�---.LTH DEP-,FTr.1EIIT 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 certiiy that i nave prepared this application and that the work to be performed v✓ done in accordance with all SFU JoAQUina <br /> COUNTY Ordinance Codes, Standards, S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:x /4M yYJO�t' QJLcOf t-1�DATE: 0'y <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required T;Nr <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmelnation <br /> to the SAN JoAOUIN COULJT'! EiiciROtiMENTAL HEALTH DEPARTLIEHT as soon as It IS available and at the Same time It is pl � r <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> C01.1L9ENTS: <br /> ✓O 20 <br /> y FN�jR Q�7N �.9 <br /> T ON CO <br /> MFNT <br /> ACCEPTED BY: [AAMEr14PLOYEE#: n DATE:20 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Sen ice Completed (if already completed): SERVICE CODE: O PIE: <br /> Fee Amount: GJ� QU Amount Pai {s, 06 Payment Date )� V <br /> Payment Type plc— Invoice# ` Check# sZbb Re'cei ed By: <br /> EHD 48-02-025 \ \ SR FORF.1 Golden Roo) <br /> 07 17 08 <br />