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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property -.7iel,ii:'.-57_ FACILITY ID # SERVICE REQUEST # <br />I OWN ,R). OPEVFOR/7 <br />CHECK if <br />/6'. Crel: //er r?? BILLING ADDRESS <br />FACILITY NAME / 7x.. <br />SITE ADDRESS <br />/ 7 /7 S Street Number Direction <br />n ..4))7 z474A'ivi‘- 0,24- <br />Street Name /7 ,1e7 City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. ' <br />E C-7Y1 (4 >4 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />citi) 2)/4 / /7 - 1/ 1/ BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR le=3,--.2 CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />/6-‘4.ZX/2(_ 6JL <br />,,,, .. „7z) PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS <br />/// .-5-6//e?./1 W&/ <br />FAX # <br />( ) <br />CITY _s /6,7 6 _,/,2,/ STATE(6; / ZIP 9' 2 c--' l <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:._ 2 DATE: <br />PROPERTY! BUSINESS OWNER ID"OPERATOR / MANAGER ID OTHER AUTHORIZED AGENT d <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 provided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: Fr_)6! Ve/k4 f--e 'r-flcre_c,f-i- -J-n <br />COMMENTS: <br />(-- <br />PAYMEW <br />RECEIVE' <br />JUL 2 1 201 <br />SAN JOAQUIN COI <br />FKIVII1 111-v14U <br />ACCEPTED BY: <br />,v.- <br />EMPLOYEE #: DATE: <br />. <br />1411119LPARTN <br />ASSIGNED TO: M eil */1) \ 1 %vili EMPLOYEE #: DATE: :VI <br />Date Service Service Completed (if already completed): SERVICE CODE: c,C)(..el 13 I E: I Of; <br />Fee Amount: \.2(5o Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />Title <br />5 <br />NTY <br />ENT <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08