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4� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M i Ci o 0S <br /> O /QE1 //// <br /> i NER P5RATOR 1 rQ V' - A L.1 �^� CQ CHECK if BILLING ADDRESS <br /> FACILITY AME <br /> o 1 4A- <br /> SITEADDRESS �r'zl'l(rc <br /> cab Street Number D reotlon ¢V t 'Street Name C �iCode <br /> HOME/o//rI^^MAAI^ILING ADDRESS (If Different from Site Address) Yn �/t�' /Jd _ Nall rl; LIT /'o� <br /> YW Street Number /�./rlL me FF'- Street Name L/ <br /> CITY STATE ZIP <br /> G C�/7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (-Lx ) 8- 51 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUITOR <br /> O Om CHECK if BILLING ADDRESS <br /> Illal-SLIn 0,) <br /> BUSNIESS WAME _ P-H-ONE# EXT, <br /> ( / - :516 <br /> HOME or MAILIT AgDRESS FAX# <br /> 4 0 k 4- A,� 5irr ( ) <br /> CITY 0 STATE ZIP n /� <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 i <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 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, STAYTF a2d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' ( DATE; 19 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTH ER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titter <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ry)'( oco �Ar InzpQc�cn <br /> COMMENTS: <br /> %� ? ?019 <br /> 0�gQON <br /> NFALt8 pEp�RT,4t I Y <br /> ACCEPTED BY: ) ,Irl WAD <br /> EMPLOYEE#: DATE: 11-20-11 <br /> ASSIGNED TO: / vMI/r EMPLOYEE M DATE: <br /> Date Service Comp�le�tlerd11 (if a ready completed): SERVICE CODE: 0(01P 1 E: I toa? <br /> Fee Amount: 152 Amount Pai Payment Date // 9 <br /> Payment Type (�� Invoice# Check# /jj93� C3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />