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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Sa1)21:g-4-- <br />OWNER / OPERATOR <br />CHECK if \iv n ScA. Co -1-Ci BILLING A DDRESS <br />FACILITY NAME <br />\U‘O•n.r)C1 I tata <br />SITE ADDRESS ).w % <br />Street Number <br />SI <br />Direction <br />5a crAryverci-O <br />I Street Name <br />st- • 1-Cot/.1 <br />City <br />GI S2,40 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />t t 2_crl pv \-\-CA.Me C_.v ra Street Number Street Name <br />CITY <br />W MO <br />ST ATE <br /> pc 1C )\,tP q 7D <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE g2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />\kir( 5SCJ-- Cil 1—CA <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME . A fl CO et -t-ota <br />PHONE # <br />FIN z•-yo 2-c,2 uf <br />EXT <br />HOME or MAILING ADDRESS <br />I 1 1crl ek k TrA vv\os c.. <br />FAX # <br />CITY (...iut 1 _t_ ,..., ,,,.., <br />1 ru r i <br />0 ATATE ci P(r) a <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, STAT and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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 />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 0 Ct VtAtil GU k VVCDVe01/(V‘_ <br /> <br />IFT <br />COMMENTS: <br /> <br />SAN do 4 2 i 4 0/9 <br />HEA411;;QUIN C <br />444"Ai r <br />ACCEPTED BY: ,y1/ 6 VkirM0 EMPLOYEE #: DATE: <br />ASSIGNED TO: . fitkik EMPLOYEE #: DATE: <br />Date Service Completed (if already co pleted): SERVICE CODE: Q0 P/,: I (CO S <br />Fee Amount: 4 1 ..? .00 Amount Paid Payment Date <br />Payment Type (c.o-k____ Invoice # Check # Received <br />Title <br />EH D 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)