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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '�:;►2col C,-I 5 01 <br /> OWNER/OPERATOR^� <br /> Vo, N1t� v��fo ro CHECK If BILLING ADDRESS <br /> FACILITY NAME , <br /> SITE ADDRESS �3� S CajI IATI�n1U S� 1/S�v6v-' vl 1 03 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ((if Differentfrom SiteAddress) JL4-33 S} tn, 5 (CAL)S <br /> 143-3 �' ,7�C"t✓1\ J��'�.U J S�' Strec[Number Street Name <br /> CITY G6L k 0.STATE ZIP Z0(0 <br /> PHONEN1 EXT. APN# LAND USE APPLICATION It Yl <br /> ( q) gos-qua <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> -DCA Q, � -61.)-C IA Yb S�'YU <br /> BUSINESS NAME PHONE# ExT. <br /> Dri V1 f ( C S k o S" yoo7 <br /> HOME or MAILING ADDRESS FAX# <br /> S. S-fYAnISktvS S1 I ( ) <br /> CITY L K vA STATE ^ 19 ZIP Z v, <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 plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, AV,S <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l6=_ DATE: 10 117//Y <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 'flue <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 inforQr action <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided to TJ6�r <br /> my representative. r1 7 <br /> TYPE OF SERVICE REQUESTED: rao CI�Y15 N�` <br /> COMMENTS: (�/1 v^ ('� �, t S ✓ ! `L` <br /> �/ O <br /> l�Vl� r7.� V.Nv'ty� �iV(_�t_CnC� <br /> 1�0174 go, <br /> PY2U"16 LIS Ih f 1144 <br /> ?ro fe �+ boR S vPq! <br /> J �J FN <br /> ACCEPTED BY: N . rnwpN O EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ C n\ �� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q� PIE: , OZ <br /> Fee Amount: l Q Amount Paid/S-, o o Payment Date 19"17//9— <br /> Payment Type ( �(� Invoice# Check# Rd6ivetl By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />