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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR _ , <br />M A I )-\ elr SUll.. (0 CHECK if BILLING ADDRESS <br />FACILITY NAME <br />2,0_, SUistb C_C-Ca__ 0 V 1?, <br />SITE ADDRESS 21.1,-2 <br />Street Number <br />j . <br />Direction Street Name <br />) ap,?tC LD <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 2_0(.0 Z <br />Street Number <br />.--.1 r A-kr- <br />Street Name <br />CITY Kejr-c,e62( STATE 06c ZIP 671 S LA <br />PNIVE el ExT. <br />11*30 VA 3 - -z,pq Lto <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR M A,‘ H-e { S14 10 CHECK if BILLING ADDRESS <br />BUSINESS NAME - , s c 02A__ T v D P#. EXT. <br />HOME or MAILING ADDRESS <br />-2_00 -2_ -F--k r A\--v-e__- FAX # <br />( ) <br />CITY STATE N 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 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: <br />PROPERTY / BUSINESS OWNER 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 prisyided to me or <br />45) TYPE OF SERVICE REQUESTED: .0,0 (-\ N.1 OA I CLC, OS Peri-VW\-- <br />COMMENTS: pczo AAA Le 1 ,(2..4 _.k c v_ . A' <br />aliv, <br />'944''/7. °40Q4,04,c02°49 <br />0 <br />ACCEPTED BY: \.1 y \A a/N 1(1/0 EMPLOYEE #: DATE: 0 2 _o i _1(.1 <br />ASSIGNED TO: \I - . EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: D..0 P/E: 4g03 <br />Fee Amount: 4 \c,-z _ Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />Title <br />my representative. <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)