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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Mobr' Ic T��( �er 5r - <br /> OWNER/OPERATOR SILI�(AI0 V/ Pe S� <br /> Ot V f ,.. C^HECK[If BILLI�NG2�ADDRESS <br /> FACILITY NAMECA <br /> V) <br /> -I <br /> SITE ADDRESS TRESS 5 (✓,� 1 O� S J 0G� �..p� Gr�'t- <br /> V) 1 Street Number Direction Street Name Cit . I Zi Code <br /> HOME Or MAcILI/gADDRESS (If Different from Site Address) <br /> J Y7 S[reet Number Street Name v <br /> CITY p A��^ ^A _$T(1TE 1 � ^ <br /> PHONE#t \ �'tl\ ExT' APN# CAE <br /> USE APPLICATION# fP <br /> I cj) (�"( 6 C„ `8 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (tCA) 23`1 - S �I �iI <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S \0. ��� �(2^ �.� CHECK If BILLING ADDRESS <br /> BUSINESS NAMES yx-�- (_ -) �j PHO NE I ExT' <br /> HOME Or MAILIN�AVI�E$$ . ^ , y r� FA[XX#'� <br /> SS '+...LL1l IL`L i 12 W ( ) <br /> CITY V e e i'. STATE CA- ZIP 01 C 3 Z <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 applicati�on nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> rds <br /> COUNTY Ordinance Codes, Standa , STATE f10' EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /C--/// Ile? <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required �7n� <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 inf ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided �Q <br /> my representative. // ' •►/�.pe� <br /> TYPE OF SERVICE REQUESTED: Fy-d d. 1)e .L/{7 - C41' Y�••o <br /> COMMENTS: JO ' <br /> 9 <br /> h�SOF q�RC O')Y <br /> TM <br /> T <br /> ACCEPTED BY: Q.-ells EMPLOYEE#: <br /> ASSIGNED TO: ( EMPLOYEE#: P61 DATE: <br /> Date Service Complet`d (if al ady completed): SERVICE CODE: Dlo/ PIE: <br /> Fee Amount: b � Amount Paid c /,5 c?0T Payment Date 1011-7119 <br /> V <br /> Payment Type �� Invoice# Check# (40� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 01/17/08 <br /> 9S� l <br />