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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT _ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> !-) (2 0) <br /> OWNER/OPERATOR <br /> Pjn CHECK if BILLING ADDRESS <br /> v <br /> FACILITY NAME U 1� I / ' 0n <br /> SITE DD E S /^ <br /> S�tNuC <br /> mber Direction Str¢ 4 4 i ¢C de C" <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sveet Name <br /> CITY STATE zip <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> l ) IOL-Oy <br /> PHONE#2 E XT• BOS DISTRICT LOCATIGODON CE <br /> l ) 5 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE �_ �^ EnT. <br /> HOME r rN^LI A`D!t FESS U�'/I FAX 5 <br /> Sl 1cjv I ( ) <br /> CITY STATE ZIP (Y' <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:` DATE: 4- 11- R <br /> PROPERTY/BUSINESS OWNER K-t OPERA R/MANAGER ❑ J OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization t0 sign i5 required Tille <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 JOA00041O', UNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provided to me Or <br /> my representative¢^.- PA va <br /> TYPE OF SERVICE REQUESTED: vU t ( Rf► <br /> COMMENTS: <br /> SAN 9 <br /> jyl?AQQUI CONM O <br /> M�`�O PON <br /> AR ME <br /> ACCEPTED BY: e(Yr—i,<e, !_a EMPLOYEE#: DATE: Z <br /> ASSIGNED TO: L-`+ S EMPLOYEE#: DATE' 2-111 <br /> Date Service Completed (if already completed): SERVICE CODE: S�3 PIE: <br /> Fee Amount: tt Amount Paid Payment Date <br /> Payment Type ab't i� Invoice# Check# IReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> P Ro ",�530 2321 IWAUJ Y [VP <br />