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i'-''' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b11 I1 95 <br /> OWNER/OPERATOR <br /> ' _ \`rn CHECK If BILLING AOORESSO <br /> FACILITY NAME• \ \\)041 <br /> [y r� <br /> SITE ADDRESS Z625 t"I O\� �,��-- IYQ�Ccv11 I U c3 7� - <br /> Street Number Direction Street Name CI J Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> StreetNumber Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (ko,' r,)41 ' 3Z <br /> PHONE#2 EXT• 11 BOS DISTRICT LOCATION CODE <br /> (Ai6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �Io <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> Af-- ( ) <br /> CITY\`f STATE DON <br /> ZIP k <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 nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE aEO awS. /` <br /> APPLICANT'S SIGNATURE: ^DATE: , 12&L/0� Z 017 <br /> T <br /> PROPERTY/BUSINESS OWNER EJ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BI ING PARTY /hoof Of authorization f0 sign is required 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a5 It Is available and at the Same time It* V ed to me or <br /> my representative. ,/ ' E <br /> am V <br /> TYPEOF SERVICE REQUESTED: I e - 1VE <br /> Cp <br /> COMMENTS: CD Ort 2 <br /> 017 <br /> � N� OWe OUNT <br /> YH TM DEp"NNT <br /> ACCEPTED'BY: 7i NT O EMPLOYEE#: DATE: 1-7 <br /> AsSIGNEDTO: ULelli ! �C'�7 l EMPLOYEE DATE: �fIq <br /> /-7 <br /> Date Service Completed (If already completed): SERVICE CODE: SCOW I PIE: <br /> Fee Amount: Amount PaidHt l� la oZ) Payment Date <br /> Payment Type CIA-, Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />