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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> mod �r2(� • (bMIT)ISSa rnFPvI PA <br /> � )I��°� <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS t5o,rvl'k a, � <br /> Street Number Direction _ street Name. city Zip Code <br /> HOME or MAILING ALDR'SS_(I Ifferent from Site Address <br /> �u C(:)u Street Number Street Name <br /> %ITY 4—Q(�I� NATE / ZIP <br /> PHONE#1 C EXT. APN# LAND USE`AAPPPPLII[CATION# y' <br /> (2Z9) C/ 5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CO T/EF-ALC g ORI SER FCE REQ ES g OR <br /> REQUFSTOR a �L q _IC CHECKifBILLINGADDRESS <br /> 1 U 1 CCC <br /> BUSINESS NAME ( 1 Cd"* Cl��'5�-S PHONE# 9 91 � 91915Exr. <br /> HOME Or MAILING ADDRESS cccJJJ FAX# <br /> CITY '�-�'� STATE ZIP <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: 6 r+y &Wr a d,— DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT El <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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it i5 provided t0 me or <br /> my representative. __ <br /> TYPE OF SERVICE REQUESTED: 'o�� y�SU,I AY W I M <br /> 5 a r....•�:n;,..:.is .: .y.. . <br /> COMMENTS: I`n FES <br /> S 2 4 2R j0 <br /> r L tJ <br /> C SAN JOAQUIN COUNTY <br /> CSM(Yl ENVIA TAL <br /> HEALTH DE>=I'PARAFiTPJIENT <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: f•ZJ j <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (if already comple ed):v SERVICE CODE: 'C'-to0I P/E: <br /> Fee Amount: J01ZV 0 Amount Paid 6 () , 0 U Payment Date ';) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />