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AFA- 0. �-'()- 3 - l I) r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTPEIMIT <br />SERVICE REQUEST <br />Gyri <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SER1SYtStt3 t If <br />AQ <br />CITY STATE ZIP <br />'-f- C'0 7J- 15 3 <br />OWNED OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />� <br />� <br />}L <br />�� <br />Street Number <br />Direction <br />�f <br />�r <br />t�.li-�tree Name <br />i <br />ZI Cloede <br />HOME or MAILING ADDR SS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />, <br />ST6TE� SIP <br />G <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />z� <br />. <br />PHONE #2 EXT. <br />BOS DISTRICTLOCATION <br />CODE <br />(' 5-49'( <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of .00 <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 JC �,4 u�N <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. W <br />APPLICANT'S SIGNATURE — DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR / MANAIIER ❑ OTH R AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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 />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. <br />TYPE OF SERVICE REQUESTED: L( Lk)S7-frCOt--)SLJ L'T�4'�l 0!J <br />COMMENTS: —CJ \ , 1 � n <br />i <br />' v ( F L 4-- 4� T, f 67- C-4--- {,T? G �� � l�-C �-�t� <br />TIECEIVED <br />MAY 11215 <br />ACCEPTED BY: (� /1 EMPLOYEE #: DATE: J iC p Un' • <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Complete (if already completed): SERVICE CODE: �� I P I E: 4 2 O Z <br />Fee Amount:j3t�. Amount Paid Payment Date <br />Payment Type (1� invoice # Check # 11b -Z Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />