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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TaC&- .7-& ?Q 031005S <br /> OWNER/OPERATOR '�Zj PI�� �! <br /> CHECK if BILLING ADDRESS <br /> NCDInn -- <br /> FACILITY NAME <br /> TGl C o 5 L��Lp In e✓1�C.. <br /> SITE ADDRESSZ4/ ' a Y Cp CSC Ll��'1 G{SZp(Q <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) / cJ <br /> 32-S Street Number G• Street Name <br /> CITY STATE ZIP <br /> 5 CKki2,-\ C 14 CSSZO Lj <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (200 C(-7o I StS <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> Qo ) 4 0- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J���oj ack Qe � m NAO�u� <br /> I'� CHECK If BILLING ADDRESS <br /> /9 <br /> BUSINESS NAMEPypN�F# —(� EXT. <br /> 'dol COS ,N1�� � rp'� <br /> HOME Or MAILING ADDRESS .� FAX# <br /> CITY cz�' �; Ij• �-� STATE ZIP ct <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: �yyo oel _ DATE: 0I- O']- '7—L') 14I <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 assessment information <br /> t0 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. <br /> TYPE OF SERVICE REQUESTED: ✓\ <br /> COMMENTS: <br /> �y4v,gQuz ��I9 <br /> IRO kc <br /> UN <br /> ACCEPTED BY: l (� EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q � EMPLOYEE#: DATE: <br /> Date Service Completed d/(if already completed): SERVICE CODE: C52 2 —7P/E: <br /> 1 r <br /> Fee Amount:e HC�koAmount Paid Payment Date `J <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />