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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L,.,:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sri oab)-Z�� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f ^n C,VA`YV'l <br /> SITE ADDRESS �c-, \ <br /> Street Number Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 102qW�'q l—ev S o1/ <br /> Street Number Street Name <br /> CITY y�n �1,n+-c(CA STATE C n ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ' S I CHECK if BILLING ADDRESS <br /> BUSINESS NAME1 Cel C/YV P <br /> Cl (\-n2 _[�� _ <br /> HOME Or MAILING ADDRESS 1 0 l- I I FAX# <br /> .L(i� l/� V 1I/1 f C, ( ) <br /> CITY MCA4e��1 $TAT n ZIP 01 <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:- ADATE: 1I22��1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY,prop 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/big provided to me or <br /> my representative. Y <br /> TYPE OF SERVICE REQUESTED; F. <br /> ry � <br /> COMMENTS: 1 G? <br /> l %JO,q � y <br /> N �N�RO V/N co <br /> �TyOFp�F�T U'v7y <br /> ACCEPTED BY: 'N EMPLOYEE#: DATE: Z2 1�1 <br /> ASSIGNED TO: , r �Vu✓mow/-c � EMPLOYEE#: DATE: 'Z 22 CA <br /> Date Service Completed (if already completed): SERVICE CODE: l P 1 E: l VZ <br /> Fee Amount:�` 1�Z D� Amount Paid Payment Date <br /> Payment Type <A Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />