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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />PV00 11 L(I I H ,,_c <br />SERVICE REQUEST <br />VN00-770 9 <br /># <br />I <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRES4 <br />FACILITY NAME c). .4 7 <br />-Q-V i f1 <br />SITE ADDRESS <br />---.C) 3 Street Number Direction <br />1 <br />Street Name <br />I <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />.v. Ct_ i---•:- --i..___ Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(1°C) ) 3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />\ CI 1,--, Lk_ e•-•1:t <br />CHECK if BILLING ADDRESSU <br />BUSINESS NAME 0 _1 ,i- PHONE # EXT. <br />HOME or MAILING ADDRESS <br />-.,, b C___, , ry-,_ty- cr-Q___ S i <br />......) <br />*\ ) ) <br />FAX # <br />( ) <br />ciTy L, , STATE 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 ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 prAded to me Of <br />my representative. A <br />TYPE OF SERVICE REQUESTED: PO UCA votue .14-1sr oiOn <br />Reci"`;11, <br />IVC <br />COMMENTS: <br />I: <br />MAR 2 4 <br />SAN ,„ 20P <br />'t-,AQui <br />Hp2IVIRONZ cNrAtouNn <br />ARNE.Nr <br />ACCEPTED BY: Kw toll 4 th EMPLOYEE #: 00.2,0 DATE: 3i.)LI I -1 <br />DATE: ,2 LI n ASSIGNED TO: 0 00 <br />EMPLOYEE #: 9zi (6 0 <br />Date Service Completed' (if already completed): SERVICE CODE: Ec 0 (2 I PIE: I tp ob <br />Fee Amount: <br />q I 1 <br />Amount Pai i 'q. y,) Payment Date <br />Received By: de— Payment Type Invoice # C,eck #(10(711 _lit' ,//'(:):--) ----7 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />ti9vovekimetc)Rogoirtoe