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r-. <br /> SAN JOAI, A COUNTY ENVIRONMENTAL HEALTI. _EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propert FACILITY ID# SERVICE REQUEST# <br /> Taco 'IFEv oo —Ppcezg <br /> OWNER/OPERATOR <br /> I it yr /I r�aaml'2' CHECK If BILLING ADDRESS� <br /> FACILITY NAME / 2 s i/�4(�G.O -C.• <br /> TE ADDRES <br /> Street Number Dir n 0 � efN¢mel i 21 Code`' <br /> iFIDIt7E or MAIIPNG ADDRESS (Ifa $rite Address) <br /> Slr¢¢[Number Street Name <br /> CITY I��^^ �E �(]^ <br /> P%QNE#' �(1APN# LAND USE APPLICATION# <br /> E'Y+r#'Z� BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE(jumok � <br /> J C, CHECK if BILLING ADDRESS� <br /> BUSINESS NAME / ^ rt C PHO S <br /> HOME or MAILING AD O f� (�l�J J (AX# ) <br /> CITY I J S= 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. G 1 <br /> APPLICANT'S SIGNATURE: ` LLC9r DATE: I I l <br /> ,PROPERTY/BUSINESS OWN3E S— OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY proof Of authorization to sign IS required Title <br /> AUT ORIZATION 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 a5 soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. WMENT <br /> TYPE OF SERVICE REQUESTED: V VAI Mf. VY I V <br /> n' RECEIVED <br /> COMMENTS: <br /> N 0 WY" JAN i 9 20V <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I /1 /.e In/Kb IA_ EMPLOYEE#: DATE: i lq/I7 <br /> ASSIGNED TO: n �� t`/WVi\I yJ 1" {-'7y�'� EMPLOYEE III: DATE: I Ill <br /> (7 <br /> Date Service Completed (if already completed): 1 SERVICE CODE: G pi E: u?J <br /> Fee Amount: 3 Amount Paid 3 c/ V U Payment Date <br /> Payment Type C� Invoice# Check# Received By: .x <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />