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! • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII-ITY ID# SERVICE REQUES # <br /> �dDY ART �j� eb�Sl��2 <br /> OWNER/OPERATOR <br /> V1 f /Ore M OMA CHECK if BILLING ADDRESS tis <br /> FACILITY NAME C-,Rq MAiN TATTOD <br /> SITEADDRESS 200I�A N li N ST (T V�kI vN q rv2 E3 <br /> Street Number Direction I t Street Namey.1 City i ✓ZipLC_oVde <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (2M 351 -- (o 0 9 g <br /> PHONE#'% EXT, BOS DISTRICT LOCATION CODE <br /> �Wq 05 <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR A n 1 & CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT.rA7T vI� FAT-100 <br /> (2_CqgZZ—c�llq <br /> HOME or MAILING ADDRESS FAX# <br /> 1 — PVNGZQxic <br /> CITY m!'Ian STATE CQ ZIP q C^7 0 G <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 /> 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, j, �/ � T <br /> APPLICANT'S SIGNATURE: L/i L!' .GJ C�C�I�I���� DATE: 4elb6)Z'"L/I tP <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> UTHORIZATION 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 /> to 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. / �] nDA ikg. <br /> I Tv,De nr SERVICE REQUESTED: (OnS Ik r1h+ R <br /> II, 7' <br /> COMMENTS: <br /> (�Oa� RSk SAN JUN 3 0201 <br /> 'JOAQUIN C <br /> HEAC�H RD.,ENTAL <br /> 7�' <br /> n r'L4C Nr <br /> ACCEPTED BY: '(�S j EMPLOYEE#: -1,4-Lt <br /> L DATE: Il <br /> ASSIGNED TO: * j 0 V EMPLOYEE#: �LDATE: If.bA <br /> Date Service Completed (if already completed): SERVICE CODE: U PIE' <br /> Fee Amount: Amount P a��Payment Date).(.n 130 / V <br /> Payment Type 40- Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />