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1 <br /> SAN J&OUNTY ENVIRONMENTAL HEA ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `-�)17 Si;ze-o �71-1 --7 ;)-y <br /> OWNER/bPERATOR CHECK if BILLING ADDRESS 0 <br /> ('�A1�6' ��g►h-a2r►w� <br /> FACILITY NAME <br /> SITE ADDRESS W +�"e �'00Ar ``^ <br /> Street Number Direction Street Name 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. APN# 2 LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADD ESS <br /> BUSINESS NAME C a I ?h Q�Q ��.y�s{-Y C� (/•� "Ic— PHONE# _ <br /> t(C2a-a0� I ) <br /> HOME or MAILING ADDRESSFAX# <br /> ( "77 5 yV1 I2Y� FAx <br /> (N) 2,qz- ZoS L <br /> CITY C„ STATE (2A ZIP (qJ 1/ <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 /> also certify that I have prepared this application a that the wo to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F DERALM <br /> �K <br /> APPLICANT'S SIGNATOR DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 C CA1-4 CL&CA' <br /> if APPLICANT 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 /> t0 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. PAYMENT <br /> I 9-ti <br /> TYPE OF SERVICE REQUESTED: I CbjL��Er-FiIvg=-n <br /> COMMENTS: <br /> AUG 06 <br /> SAN JOAC.!Jbi ;OUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> 2 <br /> Fee Amount: 22 d0 Amount Paid ,5--00 1 <br /> Payment Date g (' 13 <br /> Payment Type Invoice# Check# &?0 0 Received B : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />