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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERInATnOR r� �� <br /> �I„ � C-ICHECK If BILLING ADDRESS� <br /> FACILITY NAME <br /> !T fA �bor Mob' ) Holme{{_ <br /> SITEADDRRE^SS (U• 11 I��h AGa me o q�dd <br /> / �90QI! Street Number Dlrectlon Streel Name i ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Slre¢t Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> I 1 0 ) 733oul <br /> PHONE 42 Exr. BOS DISTRICT LOCA( N OE <br /> ( ) O —L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� Ipuz <br /> (l F CHECK If BILLING ADDRESS <br /> BUSINESSNAME AC�amS YVU1Jecif 11 -KCS PHONE# Ev. <br /> r 910 I 31SK-a <br /> HOME or MAILING ADDRESS / / f^ e /T� FAX# <br /> CITY acfGwleal STATE CA ZIP <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 and that the wort a rformed will be done in accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE a ERAL laws �> �J <br /> APPLICANT'S SIGNATURE: DATE::� g�a �ID <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof Of authorization t0 sign IS requirOrThie <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 information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is providot0 me or <br /> my representative. �_I <br /> TYPE OF SERVICE REQUESTED: C L �- <br /> COMMENTS: llkB <br /> h�4 "'?0 Cp�N/ <br /> FayRr i�14 <br /> ACCEPTED BY: aed EMPLOYEE#: DATE: <br /> ASSIGNED TO: _ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: nr� PI a <br /> Fee Amount: L ! Amount Pai ,D 0 Payment Date 9/y//9- <br /> Payment Type Invoice# I Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/77/08 <br />