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y a <br />• ''SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />'P L k -t-4 2t% U 1 FYW S P 0 <br />FACILITY ID # <br />BUSINESS NAME <br />W A t✓ Te-►� (jrc C 1. r~c. I�2�e �, <br />SERVICE REQUEST # <br />2 �J('prI Fv Ei� <br />EM' <br />D 00 / .57o <br />�o v �( <br />OWNER/ OPERATOR <br />C O1`4 O C O ? 4 I L C t p C <br />SAN JQAOUIN COUkTy <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Cc -CO C O? 41 G l L P S <br />`i T <br />PEFENVIFIONM Ir�� <br />I�bT6i;�-R <br />SITE ADDRESS <br />- <br />IM C'::(Z r{ - <br />Date Service Completed (if already Completed): <br />S TO t44c 1-0 I -A <br />Gf $' Z [ O <br />T t7 ( Street Number <br />Direction <br />Street Name <br />Payment Date <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS Different from Site Address) <br />Check # 3-7 a — <br />^(If <br />606 9- i^r 2 A S • I r Q rz- '(> Street Number <br />Street Name <br />CITY 11 O U S r <br />}—{ <br />STATE T/K ZIP <br />(APPLICATION <br />PHONE #1 EXT. <br />( 1 <br />APN # <br />0�9cS03D <br />LAND USE # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR In I C I / J� <br />'P L k -t-4 2t% U 1 FYW S P 0 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />W A t✓ Te-►� (jrc C 1. r~c. I�2�e �, <br />� <br />PHONE # <br />EM' <br />HOME or MAILING ADDRESS <br />P Bo1C r0Zr <br />MAY 2 8 2008 <br />FAX # <br />(cfI& <br />SAN JQAOUIN COUkTy <br />CITY 5nA � ^ -- t <br />7 <br />STATE C A <br />ZIP C s / <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 <br />or 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 SAKI JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and kEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />4 -5 /0'8-�h�,,. <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L11 C6 K�r(Z y- •� <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />'P L k -t-4 2t% U 1 FYW S P 0 <br />COMMENTS: <br />ECE <br />L=c� <br />Ul D Lz <br />MAY 2 8 2008 <br />MAY 2 8 2008 <br />SAN JQAOUIN COUkTy <br />EIVVJRt'��ia� El f T <br />ACCEPTED BY: <br />fT !, <br />PEFENVIFIONM Ir�� <br />I�bT6i;�-R <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />( <br />PIE: Z2 <br />Fee Amount: � <br />Amount Paid a — <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 3-7 a — <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />