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r. AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fZ.E T A-( L FU E�L `�: �:> /zw ()o <br /> OWNER/OPERATOR <br /> !`(,� � w,1 S T- ��(ZQ L E V CHECK If BILLING ADDRESS <br /> FACILITY NAME L f`A C t-t- SJ^ I„ 6 L,L <br /> SITE ADDRESS W "(5 A%,KC k(�� 2 _ b q -2 1_ <br /> �1 Street Number Direction v Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 0 / <br /> 2' k t 6, �u S ` Street Number Street Name <br /> CITY S A G R A• ;AA �—e� STATE C A ZIP y <br /> PHONE#1 I F ExT• APN# LAND USE AP/PLLICATION# <br /> ( qi(o ) I-lq3 – O89' o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /Pr L� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I t /R L�n_/ I�_n r _ � r �` PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> iv zS- ( 916 ) 3 4 - cry 2— <br /> CITY 1 t ) C STATE C 4_ ZIP C?S6 R <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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA E and F DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: S�l 3 <br /> PROPERTY/BUSINESS OWNER[3 O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E3 <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 /> Im <br /> TYPE OF SERVICE REQUESTED: ( A-K <br /> COMMENTS: MAY 2 8 2008 <br /> SAN <br /> ENVRONMENTALQUIN TM MAY 2 8 2008 <br /> HEALTH DEPARTMENT <br /> T; <br /> ACCEPTED BY: _.� EMPLOYEE#: 26 C 91 <br /> ��Il��/�F' <br /> ASSIGNED TO: C � EMPLOYEE M DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: P JE: 2k <br /> Fee Amount: 2 L Amount Paid Payment Date $' <br /> Payment Type ✓ Invoice# Check 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />