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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> R,F, O C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> `TRe- '7-7-11 <br /> SITE ADDRESS PcN CI ST R TCC CA <br /> 2 -20 Street Number Direction FN/ Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /' N� TE10 f,5 <br /> treat Number lS) Street Name <br /> CITY STATE ZIP <br /> �Mpf C-y 6P C I 'i 4 <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (5-111 ) 676 - 9fbo <br /> PHONE#2 Err. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q /I <br /> KR HF}HI KrT CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 20 8a -�Soa <br /> HOME or MAILING ADDRESS FAX# <br /> —191 N ET N ( ) <br /> CITY R STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: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 <br /> or 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 th he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA E acld DE L laws. <br /> APPLICANT'S SIGNATURE: DATE: t JP1o2 2-v <br /> M <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR/MANAGER OTHER AUTHORIZED AGENT❑ aIH a90P— <br /> IfAPPLICAN7 is not the BILLINGPARTY proof of authorization to sign is required UTitle <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 at the same time it is <br /> provided to me or my representative. /� <br /> TYPE OF SERVICE REQUESTED: C.(��ISULI O/ ' AY4q <br /> COMMENTS: <br /> 2 <br /> Cha�9� o�u��rsh�P �JO Bozo <br /> ENVIRON N� <br /> NEALTH COU � <br /> ^ _ pE TrAI <br /> ACCEPTED BY: 1/1� C EMPLOYEE#: 3 DATE: <br /> ASSIGNEDTO: WWIel <br /> C.� EMPLOYEE#: g� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: l�pOZ <br /> Fee Amount: J `,IOU Amount Paid I Sa r Payment Date 12—/212—C) <br /> Payment Type Invoice# Check# (D 3 Received By: <br /> EHD 48-02-025 yy SR FORM(Golden Roodj,., <br /> REVISED 11/17/2003 <br />