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SAN JOAQL..4 COUNTY ENVIRONMENTAL HEALTH vEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# "-;ClRVICE REQUEST# <br /> lkAA03 <br /> OWNER/OPERATOR n n,n, A r�� C1 fJA PA��� <br /> l!^ CHECK If BILLING ADDRESS <br /> FACILITY NAME J C C 0� � -11 ,t W 2 1 1 <br /> SITE ADDRESS 31 S ^ -1, � U� `�'f <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 1� CI <br /> Street Number Street Name <br /> CITY �Ii .kAxn STATE /4 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Qt11> �l?�1-2u51 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE DREQUESTOR <br /> REQUESTOR ` (A/,, (?dA kDe u f 1 I (, <br /> C 1 C CHECK If BILLING ADDRESS <br /> BUSINESS NAME Y� nvv �A /'� �� ' n�2 ' P (J, ol� I— 20e,IExT. <br /> HOME Or MAILING ADDRESS Z30 1 "F n W�� FAX# <br /> ( ) <br /> CITY ( G STATE ZIP S'7 !- <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: ` ehx,'`t?ck DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR MANAGER OTH AUTHORIZED AGENT ❑ <br /> If APPLICANTaS/lot 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: -14* <br /> hE9�T'O C <br /> ND PMRN04/At <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> A <br /> ASSIGNED TO: 1 �C In EMPLOYEE#: DATE: —1`<✓ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:PIE: `(t� 7 <br /> Fee Amount: 41 1G-2 .0Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />