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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 G\ -007 1 <br /> OWNER I OPERATOR <br /> CHECK BILLING ADOREJ✓)I\JZrsl L <br /> FACILrrY NAME <br /> SITE ADDRESSf(�YP(plf� ,s}oci�}0th <br /> 1 I Street Number Direction Street Name C ZI Cotl¢ <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE Q EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> WO <br /> oVr; 1/ Vp �J CHECK If BILLING ADDRESS <br /> BUSINESS NAME C )s r kid'I'Poo <br /> C� Pjas ler) PHONE# — L96 Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> TS-70 6 M10421 Ave- <br /> CITY 1 y) STATE G rd ZIP vs_ D T <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 /> also certify that I have prepared this application a that work to be pert med will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a EDERA aws. ,-�) <br /> APPLICANT'S SIGNATURE: DATE: 03 "Q/"/ -'W <br /> PROPERTY/BUSINESS OWNE OPE M OTHER AUTHORIZED AGENT ❑ fires olbi <br /> IfAPPLICAN is not the BILLING PARTY proof of authorization to sign is required Tule <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 environmentaUsite 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. A <br /> TYPE OF SERVICE REQUE <br /> ,S <br /> �TE <br /> CD: '�,,S C� r PA PlANoqll <br /> COMMENTS: jQ e�G y�,�'re r S�'�' <br /> ` RECEry <br /> ZED <br /> nb}Qll 2 View (-tavl�AicS <br /> T_e) htll LP tO code c1,x .vloel 17ro&w Cove_rS ")µK 0 9 2010 <br /> rrts tq l l nein PetA Pttarr-e.-S ar7q) �Tj 4(O t) e- SAN JOAQUIN COUN1y <br /> ACCEPTED BY: C-\. " \ EMPLOYEE#: iD <br /> ASSIGNED TO: Y EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:5Q 0 G., <br /> Fee Amount: Amount Paid .- Payment Date .3 20 <br /> 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />