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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00201 y-2- <br /> OWNER <br /> OWNER/OPERA" <br /> �7 <br /> I ��U K O„ 1 0� f" C CHECK If BILLING ADDRESS <br /> ��]] �u r ['1 U <br /> ' FACILITY NAME —T �. <br /> I (J( f t CA CA 1 C-5( ff f f <br /> SITE ADDRESS S /,_ `'t vO)6 t Cly S T <br /> �3 Street Number Direction ��l Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S�le') C* r 4 V!�-a/S- <br /> PHONE#t EXT• APN# LAND USE APPLICATION# <br /> 6") 5 ja ry ti o <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r CHECK If BILLING ADDRESS <br /> m Cl <br /> BUSINESS NAME I PHONE# EXT. <br /> Ix S ! <br /> HOME or MAILING ADDRESS FAX# <br /> I ( ) <br /> CITY )Lc-k /t CST�yrE S-2 I <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 b( billed to me or my business as identified on this form. <br /> also ceriify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordlrcnc, Coues, Standards,STATE and FEDERAL laws. # <br /> APPLICANT'S SIGNATURE:- ��(L�rc� JnjY2dS �t � )�U DATE: /O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I 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 /> to the SAN JOAO'11N COUNlY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is provided to me or <br /> my i6presentative. <br /> TvPE OF SERTCE REQUESTED: <br /> COMMENTS: PAYMENT <br /> (RECEIVED <br /> OCT 21 201 <br /> SAN JOAQUIN COUNTY <br /> - — L <br /> ACCEPTED BY: EMPLOYEE#: �LEf I T <br /> ASSIGNED TO: v l �) EMPLOYEE#: DATE: `f'• <br /> Date Servk:e Completed (if already completed: SERVICE CODE: ( P I E: p7 <br /> Fee Amount: C _ Amount Paid f 3 c9.(�:,p U Payment Date �'(., t !r( <br /> Payment Type C Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />