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SAN JOAQt11ta COUNTY ENVIRONMENTAL HEALTH bCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# :1SERVICE REQUEST# <br /> ":5L DOS o [S�+ <br /> OWNER/OPERATOR PIT 1 (1 �Q `�r l in 3^� <br /> .11-.w./1, ` 'v //� V CHECK If BILLING ADDRESS <br /> FACILITY NAME vogoS Oou �T e,} et C dJ��� s <br /> SITE ADDRESS (--I�\ll�...I S` I I�1�,(Coy-i 7C�K./� L <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) '':�-32- 1 -('A <br /> (' `,�l r .t <br /> Street Number Street Name V2 <br /> CIN � , '/ 1 _ STATE �r ZIP 01 S2L�� <br /> PHONE#1 vE{/r,J EXT' APN# LAND USE(APPLICATION# 1 <br /> (Z7n 21�f- v2,1 to <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR yY r�^S� M�( ,1 t-h�r) D <br /> 1'-S ( r' 1 1 ' ' 7 I v CHECK If BILLING ADDRESS <br /> BUSINESSNAME CJ <br /> ^yt•t /,�� p, C tS PHONF# _r.�� <br /> EXT. <br /> HOME or MAILI GADDRESS- lWu7 Ir r1/ LC, l FAX# V <br /> CITY STATE OA ZIP LiTS�� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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: DATE: O2'U�I'LV 1 <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13If APPLI T is t the BILLING PARTY,proof of authorization to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assessmentation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prov) f YTS <br /> my representative. <br /> TYPE OF SERVICE REQUESTED:,(, <br /> COMMENTS: <br /> ✓ ?© <br /> H�CTHp0P,f q1N <br /> Ai?TjyFh <br /> ACCEPTED BY: \ • I Y yUV� V U EMPLOYEE DATE: l <br /> ll Al\I,lilq <br /> ASSIGNED TO: _ .n �.n 0 S EMPLOYEE#: DATE: v- l <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I�ou <br /> Fee Amount: `C�2 --� Amount Paidp /Sar 0D Payment Date <br /> -A, <br /> Payment Type v+ vv Invoice# Check# $73 - -2— Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />