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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L cPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FIACILIT�YiID # <br />CHECK If BILLING ADDRESS <br />SERVIICCEE RECQQUUE�S�T# <br />tlj'7i/ITI../ <br />=fl\ <br />M `-7'CS- <br />�� W' apk 1 <br />OWNER / OPERATOR <br />FAx <br />©[� h�lT& NtijFC <br />FpAgN <br />CITY �c tt <br />O N <br />CHECK if BILLING ADDRESS11 <br />FACILITY NAME <br />C7O/ <br />ACCEPTED BY: ClQ ICrk C.. / S LU <br />EMPLOYEE#: <br />SITE ADDRESSstge I 3/�/7''/�J <br />Lber <br />DATE: <br />ASSIGNED TO: -,LCA <br />D� <br />EMPLOYEE M <br />S et DlreeHon <br />—" `StraefName <br />Date Service Completed (if already completed): <br />CI <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />P": D <br />Fee Amount: O <br />Amount P44 3 , 0 <br />Street Number <br />Payment Date F-1 / <br />1 <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 E%T <br />I R ceived By: <br />APN # <br />o°I z <br />LAND USE APPLICATION # <br />Qq 6 -leu <br />so 1, <br />PHONE#2 Exr <br />BOS DISTRIr <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />NAME <br />�� '- <br />�BUSINESS <br />PHONE # <br />V xT' <br />HOME or MAILING ADDRESS y <br />/ <br />C CCS / /�J <br />FAx <br />©[� h�lT& NtijFC <br />FpAgN <br />CITY �c tt <br />O N <br />STATE <br />zip O <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 <br />COUNTY Ordinance Codes, Standards, <br />APPLICANT'S SIGNATURE: <br />PROPERTY I BUSINESS OWNER ❑ <br />If APPLICANT i5 not <br />the work to be performed will be done in accordance with all SAN JOAQUIN <br />/—,-- DATE: �r 10— <br />NAGER ❑ OTHER AUTHORIZED AGENT �i e!5�-esl Cp <br />proof of authorization to sign is required Title <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 environmental/site assessment inforrWion <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 <br />my representative. FH <br />TYPE OF SERVICE REQUESTED: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />7019 <br />UN/y <br />FNT <br />COMMENTS:1/ 4f L d !i( <br />n`S'J <br />/�1/�/�7 <br />/�U/ 17 <br />�-{� <br />D yJ if L/X INZ�% Lrf k,t <br />/ <br />C CCS / /�J <br />1nt� <br />V/ / <br />©[� h�lT& NtijFC <br />FpAgN <br />U � <br />C7O/ <br />ACCEPTED BY: ClQ ICrk C.. / S LU <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: -,LCA <br />EMPLOYEE M <br />DATE: Co <br />Date Service Completed (if already completed): <br />SERVICE CODE: — <br />23 <br />P": D <br />Fee Amount: O <br />Amount P44 3 , 0 <br />Payment Date F-1 / <br />1 <br />Payment Type <br />Invoice # <br />Check # ! l <br />I R ceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />7019 <br />UN/y <br />FNT <br />