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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �"�v�ool�5 s�o��v3b <br /> OWNE OPERATO <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 1 � V [/1 111 { 1��I t� tJ J "L U l ► 1� <br /> SITE Ail R <br /> � � ��/J ///J�/jam/ <br /> Street Number DiYpGlron <br /> -gal) <br /> M7 Edrw,A ac ADDR sS (I ifferent(from/Sit+e Qddres P, <br /> �a � � V l J� �v Street Num6ei Street Name _ <br /> CIN 9hC4=L <br /> r <br /> qfzaq <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> M 33 4 --zoo)-L, <br /> PHONE12 EXT. BOS DISTRICT LOCATION CODs <br /> ( ) i <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> R ''j y <br /> UESTO CHECK if BILLING ADDRESS� <br /> BUSINESS NAME PN EXT. <br /> HD �[�¢�!� A 5 n FAX# } / <br /> Lxv as , <br /> CITY TE ZI 'f <br /> BILLING ACKNOVIVLEDGEMENT: 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 applicqon and that t to be performed will be done in accordance with ail SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE E ERAL I //2 <br /> APPLICANT'S SIGNATURE: DATE: Ob, / //6 <br /> '-- RL- <br /> PROPERTYI BUSINESS OWNER OP RATDR I MANAGE ❑ <br /> ICI OTHER AUTHORIZED AGENT ❑ <br /> tfAPPLtcANT 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 Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 4 r!KeAf <br /> COMMENTS: <br /> SAN <br /> JUS 1 �zags � <br /> EN�gQUlN C � <br /> kacrN of aRraFN <br /> ACCEPTED BY: 1A 11 EMPLOYEE 1: DATE: <br /> ASSIGNED TO: ie, l L -Lv EMPLOYEE#: DATE: O�j (3 <br /> Date Service Completed (if already completed): SERVICE CODE: V PI E: (��ttZ�- <br /> J <br /> VV <br /> I <br /> Fee Amount: -30. Amount Paid:-P �� 0 Payment Date /3 <br /> Payment Type � �J Invoice# Check# Received By:� �( <br /> EHD 48-02.025 SR FORIA(Golden Rod) <br /> 07/17/08 <br />