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SAN JOAQui.4 COUNTY ENVIRONMENTAL HEALTHHHHHRR�EPARTMENT <br /> SERVICE FEQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0—k <br /> ��s-�_c�U�ra► rpt _.i <br /> OWNER � <br /> /OPERATOR .. <br /> Nit 4I(I �> !It �� hAn j��Y1� � h^ CHEC!(If BILLING ADDRESS <br /> FACILITY NAME-' C tj 1' , (/q <br /> Chw(- s 1-��irY�bvt� e►� <br /> SITE ADDRESS <br /> Street Number Direction 1 �� ( ( Street Name i y Zi Code <br /> HOME 0r MAILING AD P.ESS (!f Diffe,erf from Site Add, ss) <br /> 7� 1� ° ►1 G�ti�1 it ��P yrC�' <br /> Street Number Street Name <br /> CITyr- �C �L r� STATE ZIP <br /> PHONE—J#1 I EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORL <br /> Nc 1 (k r»m eco 111 �� I//�� I '� e r)(\ CHECK If BILLING ADDRESS <br /> BUSINENAME PHONE# EXT. <br /> HOME or MAILING ADDRES FAX# <br /> �-�-'t",?, 4 C 1 i ( ) <br /> CITY CG �� � S T \ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business er oierator or authorized agent Jof same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPART ENT harges 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 ap lication and that the work to be pert rmed will e e in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST E and FE ERAL laws. <br /> APPLICANT'S SIGNATURE: P J —�'G �/ ATEA �j Z <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTH IZ ENT ❑ <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. �y <br /> TYPE OF SERVICE REQUESTED: �� 7 <br /> COMMENTS: <br /> MAY 2 8 LU <br /> SAN JO ApUIIV COUNTY <br /> ENVIROMENTAL <br /> HEALVVA 01-VARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /`/ �r� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: /�O <br /> Fee Amount: (�� Amount Paid �t�(�j�) Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />