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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> if Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F/%07'zte31 I 9K00 77277 <br /> OWNER OPERATO <br /> 74 Ile <br /> /IvIWA�PF`2 � CHECK If BILLING ADORESSO <br /> FACILITY NAME Y ./-�l J-�� / <br /> SITEADDRESS Z Z SOU/ or/-f /f✓/h/- <br /> 014kD4cr '6�4 6/ - <br /> StreetNomb¢r Direction Streel Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Si a Addres n <br /> Z toZ O Street Number Street Nam¢ <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> �t ) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> y�/ <br /> CONTRACTOR <br /> 1/ SERVICE REQUESTOR <br /> REQUESTOR <br /> OUB #P?A141VPEL <br /> BUSINESS NAME <br /> CHECK If BILLING ADDRESS O <br /> /n� PHONE# Ez. <br /> /`xnt� <br /> � rS �1102 2U9) 2 7 <br /> I`\ HOME Or MAILING ADDRESS +,. Zy A FAa# <br /> \\ <br /> CITY STATE q ZIPIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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, Standard r1aws L/ <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNERIW OP,136'/CTOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof Of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 pme or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: tA VO () �y <br /> COMMENTS: <br /> APR > > ?0 <br /> Sq N�IRQUINCOU <br /> HEAC7HDEpge MAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1•7 I'-) <br /> Date Service Completed (if already completed): SERVICE CODE: G7J- <br /> Fee Amount: J 11-3q I Amount Paid D b Payment Date 7// <br /> Payment Type Ll Invoice# Check# Received By/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />