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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY Ip# <br /> e SERVICE REQUEST I <br /> OWNER 1 OPt:tzaro <br /> (o �i 2 00g S22 <br /> FACILITY NAME t <br /> 1i CHECK U BILLING ADDRESS <br /> SITZ:ADDRESS <br /> 9s3-45 <br /> 5tret:!NumhK qkk S a alma <br /> HOME or MAILING ADDRESS (If Diffe11 r11 ent from Site Address) I ! <br /> 5q <br /> CITY �T v/ (/�� #! —Stmt Number �L me <br /> PH NE <br /> �L S � ]`C. l�� '$TATE Zip 7 <br /> Exr, APN# _ <br /> �� L)M6 USE APPLICATION ft <br /> PHOt.'E I b U� <br /> OS DISTRICT <br /> obs <br /> LOCATIONCop <br /> g <br /> CONTRACTOR J SERVICE REQUESTOR <br /> ReauE$TQR <br /> CHECK tr BIL11NG AD R SSO <br /> BusrNEsS NAME C� PNONE E <br /> HOME Or MAILING ADDRESS FA%9 <br /> CITY 1 ) <br /> STATE Zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge That all sate andlor project specific EmARONMENTAL 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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with at] SAN JOAOUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws <br /> \/,APPLICANT'S SIGNATURE: <br /> 2"' _ DATE: 12 - 2 2 - 2 0 <br /> PROPERTY I BusINESS OWNER 2 OPERATOR 1 MANAGER OTHER AUTHORIZED AGENT 0 <br /> IfAPPLtcANT Is not the BlLLlNG PARTY.proof of authortzatlon to sign Is required Thle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentallsite assessnppt information <br /> to the SAN JOAOUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is f(�vJ��tp rpe Or <br /> my representative. /I(,/I� }. <br /> TYPE OF SERVICE REQUESTED: <br /> I <br /> COMMENTS: <br /> o <br /> 4 N�AV4R0 C11NCOU <br /> rH 0 N/V EN Y <br /> 4 ACCEPTED BY: C-(f,.A S f 40 EMPLOYEE M DATE: -)L— I <br /> I` <br /> ASSIGNED TO: <br /> L,,�����e EMPLOYEE M DATE: <br /> l <br /> Date Service Completed (Itatrcadyeompleted): SERVXECODE: �(C PIE_ `+y <br /> Fee Amount: Amount Pald <br /> ,�2—' �`j,�.Q� Payment Date 2 <br /> Payment Type `.�� Invoice# Check# ` 9�D Received By: <br /> I <br /> I EHD 48.02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br /> 4 <br />