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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F o J rl- (,c K Q-oo-79 ;;LD5 <br /> OWNER f OPERATOR <br /> Vi C�l \0- � �f D a CHECK If BILLING ADDRESS <br /> FAclflI c_M l I s `G�'S 1 e- r l "-J <br /> cl <br /> SITE ADDRES /^ V KA <br /> Street Number DiZion 'r9"vIA'FT/' St et Name �-FCri Y zip Code <br /> HOME V <br /> I/�Or MAILING ADDRESS (If Differen <br /> I t from Site Address) <br /> l.it/\ ' Street Number Street Name <br /> Clr� �( _ ^ STATE �/t ZIPn 60 <br /> PHDNNEE#1 `(y- cx ExT. APN# LANDUSEYTAAPPLICAT]ON# (l� <br /> PHONE#2 ExT. BOS DISTRICT_ LOCATION CODE <br /> ( , moaal <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUpSTOR <br /> CHECK IT BILLING ADDRESS <br /> BUS NESS NAM V V ,- PHONE# ExT. <br /> `C 's Nod S -S r b S 9 <br /> HO Edd LINCz D RE p LL t FAX#PL <br /> ) n <br /> CITY /l1• V�N./1C7 W STA T ZIP q <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, STATE and FEDERAL laws. <br /> U.,[ J <br /> APPLICANT'S SIGNATURE: _4 ( &�, � ^— — DATE: � �` �O �Y <br /> z <br /> PROPERTY/BUSINESS OWNER❑ OPER OR f MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 77tte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located/p"_above <br /> site address, hereby authorize the release of any and ail results, geotechnical data and/or environmental/site assess t rif�F n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon as It Is available and at the same time it is P�l�t��. <br /> my representative. _v I <br /> TYPE OF SERVICE REQUESTED: ` J k I d-e- I ki {J ad..4ulv <br /> O <br /> COMMENTS: y41,7,, WN <br /> vrNoOeO <br /> pMNr <br /> 4 <br /> ARryFNr <br /> ACCEPTED BY: D QA r1. EMPLOYEE#: DATE: <br /> ASSIGNED TO �av'�T +I ,tel F-16 (Q)L-Z— EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECooe U PIE: U <br /> Fee Amount: Amount PaidCP/V,OD Payment Date (el-7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />