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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST" <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> +?-e(J - 60M1/Pisses rnFPO <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �© V �7 ° ' C1 <br /> CI6C�n$'-es <br /> SITE ADDRESS �� I �-O t�l� \ � 'C�G� (�'S.Z D <br /> Street Number Direction _ Street Name Citv Zip Code <br /> HOME or INIMILIIN�G A_DF:-SS (I Ifferent from <br /> /Site Address <br /> U Y Street Number Street Name <br /> i-17Y—�s'—+.OG� STATE / QIP 9��o G <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ()\Lq) ��7 q 9 5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> REQUrSTOR //{. O b e ��rq I C CHECK if BILLING ADDRESS <br /> T I �t PHONE# EXT. <br /> BUSINESS NAME S ��l C t S�S 9 O p 2 J S <br /> HOME Or MAILING ADDRESS �1 FAX# <br /> CITY \ 4 UG� � STATE Chi ZIP �J-�0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned propefiy 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 /> 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: p �r�d r C, e, DATE: Z <br /> PROPERTY/BUSINESS OWNER PERATORI MANAGER ® OTHERAUTHORIZED AGENT El <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 time it Is provided to me Or <br /> my representative. P AY r-� <br /> TYPE OF SERVICE REQUESTED: CC SLt fid` <br /> ( � � F <br /> .D <br /> COMMENTS: <br /> VL 1 C`7 F-!8 1 4 20"16 <br /> SAN JOAOIJIN COUNTY <br /> 61_4 m /SSS En;vli, EFIARTAL <br /> NI <br /> ��-I1=AL�t t 9 0:-:��-Z�tTar,EIN.,r <br /> ACCEPTED BY: EMPLOYEE#: I DATE: <br /> ASSIGNED TO: I (Ja a t 1 ,(, EMPLOYEE#: DATE: 7') <br /> Date Service Complete (if already cOmple ed): SERVICE CODE �liV P`IE: I Z_ <br /> Fee Amount: 0 Amount Paid Payment Date �a <br /> Payment Type Invoice# Check# Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> r <br />