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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />t.-- • - <br />SERVICE REQUEST <br />.00170 9 <br /># <br />1 <br />OWNER / OPERATOR <br />CHECK if <br />fs % I Lk_v--, 1.---y.\ * <br />BILLING ADDRESt i <br /> <br />FACILITY NAME c) 4 7 <br />c—A1.1-Q-4" I iss-1 <br />SITE ADDRESS <br />-• -0 3 Street Number Direction <br />--) <br />C._;-(Thr-nrr\-41-t- ('---- .--- 1 • 111 1 6 1 <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />S CA_ '-r -t...- Street Number Street Name <br />CrrY STATE ZIP <br />PHONE #1 Ext <br />Q-CDC) ) S a -) - -)s- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />1 ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESSEI <br />BUSINESS NAME PHONE # <br />() 3 -2 ) <br />EXT. <br />HOME or MAILING ADDRESS ..__J FAX # <br />Cm/ L, , STATE C 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 Of <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 ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />3 11-z <br /> <br />PROPERTY! BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pr vided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: Fut )(-A VenVA L jircr(Vtion vrzCOMMENTS: <br />4UP <br />84N JOAchp <br />ki,fNV <br />.1 <br />/R,olv: CO/ ./Air '.1.7.1 D E p -Ii,erA z. <br />AftrikENT <br />Kekt ainl y_fl {'h EMPLOYEE #: 0020 DATE: i <br />,2y <br />ACCEPTED BY: <br />0 ASSIGNED TO: % A i no EMPLOYEE #: ofq g_i DATE: n <br />Date Service Completed' (if already completed): SERVICE CODE: a u (k/ I PIE: Itp (), <br />Fee Amount: 'q e Amount Pai .7. ,):) Payment Date 34 a-7 <br />Payment Type Invoice # Check # _i , Received By: je <br />END 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08 <br />tkAWMilet 'e-A),54(/(vte