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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH gitARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SA C 6 /11)1 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ----", 1 (A.zif,5 mo -so I i_c( <br />SITE ADDRESS <br />e r Direction C-C'(-C-Yt'Lj\A4t-r\e/eRamc (,) -A <br />, <br />/ 6(1i cit, W4I0 zio code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />) Z -7)'--) %5- I \_, 1 JILL; y ci 45z-5 Street Number Street Name <br />Crry STATE ZIP <br />6 a c 1,, 2-52'1' a <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />E• <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 6--) <br />". C._ CC')CHECK if BILLING ADDRESS ' <br />BUSINESS NAME --,-- 6 OA C-ivc I CL <br />PHONE # <br />O'ort) 26 -5 <br />EXT. <br />- $ - 6 6 <br />HOME or MAILING ADDRESS <br />I 2,-3 11 <br />FAX # <br />Crry m d E STATE c- \ \ <br />Zip 9 LIC <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 Of <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: 3— 3 ti\-- )? <br />PROPERTY / BUSINESS OWNE04 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY proof of authorization to sign is required <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 is provi0c1 to Me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: .I -e_. ir-D4)-e_C+1 Or) AfA Ad' :i i <br />COMMENTS:&IA, <br />' <br />0 1 la rCi-e- 44 <br />OV3n er <br />.,T Jo/A „ <br />EA/V/p LEUN Co i%ett.7.H <br />ACCEPTED BY: c 3 (CA EMPLOYEE #: DATE: , .:_iz.") _ I - ) <br />ASSIGNED TO: ( EMPLOYEE #: DATE: 37) j ) <br />Date Service Completed (if already completed): SERVICE CODE: c PIE: 1 Lic„ If) <br />Fee Amount: \ -75ial) Amount Paid / ,) 9.., 4 () Payment Date 3/3 /// 7 <br />Payment Type Invoice # Check # Received By: /IA- <br />Title <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08