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SAN JOAQ6._ vOUNTY ENVIRONMENTAL HEALTH [ E+PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-Aov IZD�(5 /08( <br /> OWNER/OPERATOR <br /> i,_Y I C/ 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Gt Le 1 � 1 � <br /> SITE ADDRESS 1f �) ///������ G 40 <br /> I �0 - Lection �f .� sf-/ �� ci / ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> .--I/ L-" /-7— Street Number Street Name <br /> CITY -STATE-ST TE zip - O <br /> Lu 1►� <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> 6ZO-1-0 7 l'Z S y 7F <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> CA I _ A/C 6 <br /> BUSINESS NAME .-- PHONE# EXT. <br /> C. v e I`Cc '�"- 1 7/2 5 Y • 9 <br /> HQM orMAILINGIADDRE S FAX <br /> Y <br /> ,✓ �v ( ) <br /> CITY CG yn v $TATE , zip <br /> � l� <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 t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL I S. 7 7 <br /> APPLICANT'S SIGNATURE: Ct oG ( DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to 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 as It Is available and at the Same time It IS provdi Q e Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: FV 0 d V e I I f U--e --JAI I % on A4A,, <br /> COMMENTS: , <br /> o or f U IF�0,1QU201, <br /> O o <br /> �gR�r��JV <br /> MF)VT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 17 <br /> ASSIGNED TO: C/w/��✓ V EMPLOYEE#: DATE: /7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: C1 Amount Paid Payment`Date -? <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />