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SAN JOACA.IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> 1AUU2b� l � SP-00101610 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Y")? <br /> SITE A//D--DRESS E 1/� t� C I <br /> r�aW Street Number Direction CihavN tl Street Na �CG^ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) nb <br /> 4 Street Number \&r ^a Stree�me <br /> CITYSTATE ZIP q <br /> i� LA Lt /� 1 <br /> PHONE#1ExT APN# LAND USE APPLICATION# <br /> (sap) 'i a& <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L" CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E%T, <br /> a a� <br /> HOME or MAILINGADORES FAX# <br /> 45(62 ( ) <br /> CIN Oy <br /> STATE O ZIP (l S ^ '1 <br /> urv,. l� l.{ PVJ <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 prepay is application and that t work to be performed will be done in accordance with all SAN JOAOUIN <br /> COUNTY Ordinance Codes, Stand STATE and F ERAL la <br /> APPLICANT'S SIGNATU.R.yE�: DATE: Y _ Q-b I 7/ <br /> PROPERTY/BUSINESS OWNER OCJ OPERATOR/MANAGER ❑ THER 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, 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 tlm PAYrovided to me or <br /> my representative. { Vf J' M E <br /> TYPE OF SERVICE REQUESTED: fov(G II {J t U VE <br /> COMMENTS: H'y 1 `r f/ 12017 <br /> SAN <br /> OAQUIN COQ <br /> HST N ctA MHT <br /> ACCEPTED BY: i/Ll(a, A4ev,1('n(,,4iwh <br /> EMPLOYEE DATE: I <br /> ASSIGNED TO: n EMPLOYEE#: DATE: <br /> L SVICE COODate Service Completed (if already completed): , PIE: <br /> V b,/75 <br /> Fee Amount: I, Amount Paib 3 l00 <br /> Payment Date /� 7 <br /> Payment Type ✓ Invoice# Check# 102- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />