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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> :1 S to <br /> OWNER/OPERATOR Y" ` <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME r• \ VVVIII Ut,(�� <br /> SITE P'^^' CSI , <br /> street Numberon Cyt' r 1 ee[Name P Code <br /> HOME Or MAILING ADDRESS (If Different from Site <br /> b- drress) <br /> Z S Aie`P v2� -r/�� Street Number Street Name <br /> CITY STATE ZIP <br /> ��Gkrr, 61-- 9sz02 , <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( q10 'Fl <br /> y <br /> PHONE#2 o EXT. <br /> (2 q) BIDS DISTRICT LOCATION CODE <br /> 8s li <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> e'er'^r L,N CHECK If BILLING ADDRESS <br /> BUSINESS NAME Yr.'y ,nW, IU�Q� PHONE# EXT. <br /> ^/ w0" 302 00f.7 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIPp�O <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 Is <br /> APPLICANT'S SIGNATURE: DATE: DG TXI 20 9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AG ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, f of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at Ae.albove <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/Site assessment <br /> ppi <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provi �Ae� <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: .� / !J <br /> COMMENTS: ✓QCO <br /> y 19 <br /> M�TN0 V4f_ TU fY <br /> �uIs <br /> (} '9RT,yfF T <br /> ACCEPTED BY: r4' S EMPLOYEE#: ,5 DATE: <br /> ASSIGNED TO: V11"cM 14 ✓ EMPLOYEE#: U DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' PI : 3 <br /> Fee Amount: 15e Amount Paid /Sz 00 Payment Date <br /> Payment Type � Invoice# Check III �/S q3 Rec ived By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />