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SAN JOAQL,..e COUNTY ENVIRONMENTAL HEALTH L"PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAoo�2--bglo IER00?y`12s <br /> OWNER/OPERATOR I¢1� l <br /> CHECK if BILLING ADDRESS 4� <br /> FACILITY NAME <br /> a v <br /> - 2214 <br /> SITE ADDR�I <br /> (/ I r LrEi Olredion Street Name CIN Zip.Cotle <br /> OME Or MAILING ADDRESS (if Different from Site Address)~ <br /> � •��_I r Fty-(Yl ` � �'tT Stree[Number Street Mame <br /> ITY STATE ZIP ' <br /> S k <br /> PHONE#1 L;T A P N# LAND USE APPLICATION# <br /> ( > G <br /> PHONE#2 EKT. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTQR [/ CHECK If BILLING ADDRESS <br /> C( <br /> BUSINESS NAM I , /� PHONE EXT. <br /> # y <br /> HOME or MAILING ADDRESS ( FAX# <br /> / cat i f� r� 9t ( ) <br /> CITY S OLI-k11� STATE ZIP <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. / <br /> APPLICANT'S SIGNATURE: /q�/3 c�,�J&I y d f//�`��j/Cr Zr DATE: 2l <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to Sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> foo vv ISIp f1 ec un RErpaILI yT <br /> TYPE OF SERVICE REQUESTED: `j <br /> COMMENTS: �- R<<4 <br /> SgN1J 2 ¢ ZO16 <br /> ENVNf <br /> HFAl7yRDqFR 4 <br /> T <br /> ACCEPTED BY: Hqplot <br /> M"nQizholb <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: Ma I .el flo tZ EMPLOYEE#: DATE: t '( <br /> Date Service Completed (if already comoleted): SERVICE CODE: ,cr' 0 I PIE: 02 <br /> 2 _ I_ T vV -J <br /> Fee Amount: Jv Amount,p jd7 130,6V Payment Datet.�/ <br /> Payment Type Invoice# Check# Received By:� _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />