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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4`:AOO2OL(2�? g�- <br /> OWNER/OPERATOR <br /> 0II&I C r\A CHECK if BILLING ADDRESS <br /> FACILITY NAME /� L,n, —4 5-���lll ��`� <br /> SITE ADDRESS -2 1,`J_l C) l%1 �12PO2i- <br /> i <br /> Strreet Number Direction Street Name city <br /> ] Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 101 0S V,-D S T <br /> Street Number 1 I 1 Street Name <br /> CITY e:�; o / �v—` STATIX'►1 ZIP <br /> PHONE#1 Ili EXT. APN# LANDUSEAPPLICATION# <br /> (2M gel- o�2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M/„ 0 O n,^0 CHECK if BILLING ADDRESS <br /> BUSINESS NAME C h�1 �� �12ii P # /7n , ;D ,2 <br /> HOME Or MAILING ADDRESS(�o s � (^' A f� �� FAX# ) <br /> CITY I/ b1 ^ '�+:(�n-fiIv STATE C/Y ZIP ( n <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:�1 C,-y 1-0 ) DATE: I Z I Z9 <br /> PROPERTY/BUSINESS OWNExsot <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [IIf APPLICANT 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 assess ent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is pto me or <br /> my representative. �7 <br /> TYPE OF SERVICE REQUESTED: I(.h Vv; -)PC 6V �II <br /> COMMENTS: e,_A^OqQ�,3 ;018 <br /> h�,•TVtiF,lvTC,q�H�Y <br /> !1 MENr <br /> ACCEPTED BY: �n 0 W� EMPLOYEE#: DATE: <br /> ASSIGNED TO: , , l i EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0�0' PIE: <br /> Fee Amount: 1 C,2 _ �,� Amount Paid Payment Date <br /> Payment Type / Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />