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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />- <br />FACILITY ID # SERVICE REQUEST # <br />2-60C-37 ? <br />OWNER! OPERATOR / <br />S-t-Q )--Q/1,-N .(( Lt/t/1 l'"") CHECK if BILLING ADDRESS <br />FACILITY NAME <br />S411()M1 <br /> <br />SITE ADDRESS C 7s 1464 1 al P0-0- <br /> <br />Street Number Direction <br />IC <br />Street Name City Zip Cpae <br />HOME Or7 <br />0 <br />AILING ADDRESS (If Different from Site Address) <br />lc\ Street Number Street Name <br />CrrY olr Me<_,A <br />STATE ZIP <br />c ief K--0 7 <br />PHONE #1 EXT. <br />(U)°,) CZe-(— 0/) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />. <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME / <br />C friag./2 C itc700/1 (,/22717 ,.3 <br />PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADpRESiS i A / A <br />-‘7-C--, Xti- 1.457 41/ fir/ /(, (it- Dr. <br />FAX # <br />( ) <br />crry ,A <br />71 <br />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 DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERAT / MANA OTHER AUTHORIZED AGENT 0 <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availa le and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: "1v 1%-fitri.E. /4/101.0G21 P <br />_ <br />N -/- <br />COMMENTS: <br />FEB <br />5 2008 skv jo,,,, <br />evvigeovCOuN <br />/1E41-TH DPAIENrAt TY PARNENT <br />ACCEPTED BY: <br />i <br />EMPLOYEE #: 'F3(120 DATE: <br />ASSIGNED TO: Afiler4- EMPLOYEE #: (0 ept p DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 6/6 7 P1 E:a03 <br />6, ... Fee Amount:clfe, Amount Paid Payment Date :;.L <br />Payment Type,-,_. i\,., \) , Invoice # Check # Received By: , <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003