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SERVICE REQUEST <br /> I Type of Business or Property FACILITY ID 9 SERVICE REQUEST <br /> Poultry ( egg ) Ranch 004756 «q"(� <br /> CWHER I CPERATOR BILLING PART-Yo <br /> Bill Huang <br /> I <br /> FAC: NAME <br /> Carter Road Egg Ranch Wi <br /> SITE A0636 East Carter Road <br /> StreetHumbu -----n 5tn�tH�m� Type Suitt <br /> Mailing Address (If Different from Site Addressl <br /> STATE ZIP <br /> Farmington 95220 <br /> PHONE1 APN LAND USE APPLICATION# <br /> (209) 886-5687 207-08 - <br /> tBOS <br /> �2 _ISTRICT ( LOCATION CODE <br /> PHONE - <br /> i X091 886-5625CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PARTY❑ <br /> REQUESTOR <br /> PHONE'# EXT' <br /> BUSINESS NAME ___-_._-•- <br /> FAx# <br /> MAILING ADDRESS <br /> CIiY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUSL,C HE4LTH SERVICES ENVIRONMENTAL HEat-TH DNISiON hourly charges as=ated with this protect or activity will be oilled to me or my business as identified on this fort. <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 COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. f� <br /> y�,Yy4 4j- <br /> APPILICANT SIGNATURE: DATE. <br /> PRCPERTY/BUSINESS OWNER yl OPERATOR/MANAGER t] OTHER AUTHORIZED AGENT 0 <br /> 1f APP,c wr is not the Qj I s4c PAR Proot of audwrizadon to sign is rvWkW r i t 1 e <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.ate owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envirnnmentalisite assessment into mation to the SAN JOAQUW COUNTY PUBLIC HEALTH SERvicEs ENVIRONMENTAL HEALTH DtvlsloN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: _ _ --- -- -- <br /> COmDnStinn <br /> I <br /> COMMENTS: <br /> e 10 3 <br /> SAN JOAQUIN COJNT <br /> PUBLIC HEALTH,SERVICES <br /> F-tJVIRONMENTAL HEAiTH UIVIS <br /> INSPECTOR'S SIGNA RE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: I ESIPLOYEE 9: ( DATE: <br /> +• <br /> ASSIGNED TO: EMPLOYt_E"#: �Ct DATE: <br /> 'SERVICE CODE: I E: <br /> Date Service Completed (if already completed): oil ZZ <br /> Fee Amount: O I Amount Paid O Payment Date 0- <br /> Received By: <br /> Payment Type ( Invoice <br /> Check: ' b I <br />