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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> //1S F 4"'^ �S t2oo7y 13 <br /> OWNER/OPERATOR /� CHECK if BILLING ADDRESS❑ <br /> c '•1AJe. <br /> FAUuTY NAME n <br /> $ /-, p rr� <br /> ]}S.ITE ADD�$ IS�2J ✓` �S /�"U rL 'CL-5G '�.J✓ Zc� <br /> /�-S Street Number Direction ,,, Street Name CI ZI Cotle <br /> HOME or MAILING ADDRESS//(If�rDiffne/re�ntt from iite i-.fdress) <br /> /�,41V 6 1;,i Street Number Street Name <br /> STACITY C,17( /V �TE / �^ <br /> PHONE#1 O r APN# LAND USE APPLICATION# /v <br /> ele <br /> PHONE#Z EwT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' �,/1 <br /> ��1 al % "q'"A I CHECK If BILLING ADDRESS <br /> BUSINESS NAME *' QGO -,, v.n PHONE# fit' <br /> HOME or MAILING ADDRESS/ 3�- !7s� FAx# <br /> CITY S'fbG ATO r✓ SLV E `7J <br /> BILLING ACKNOWLEDGEMENT: 1, 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 he billed to me or my uasiness as identified on this form. <br /> a certify that I have Prepared this application and that:he work to b perforr gad will be done in accordance with JI ' .N %oAQUN <br /> C`JUNTY Ordinam.e Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: G* �ti�w DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS n(, Ile I3tt.LING PARTY proof of authorization to slgo-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 /> IO the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as s, on as R Is available and at the Sam,,time it is provided to me or <br /> my representb':ive. <br /> TYPEOF SERVICE REQUESTED:_ fbaV1 <br /> COMMENTS: --- -I <br /> FEe VFO <br /> SAF✓pA S ZQ�6 <br /> HFA N pE�MFNrOU <br /> MY <br /> ACCEPTED BY-: 42 <br /> V: (_` EMPLOYEE#: DATE: (J <br /> ASSIGNED T0: �e�i(/I P)o w/Wr�✓es EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P 1 E: (o p) <br /> Fee Amoun;. o� (� Amount Pal i'/ Payment Date S�, <br /> Payment Type Invoice# Check# I Received By:� <br /> W ill e,-wa4 ( <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />