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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property . FACILITY ID # <br />FA000 57 <br />SERVICE REQUEST # <br />g-ZIO <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS ., <br />FACILITY NAME <br />cksvMe_. isiS,c,Ort-KsA\C - <br />SITE ADDRESS <br />Street Number Direction <br />(94 is, 9-e:---), <br />Street Name City <br />(..) <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Ex-r. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />HOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />V\ e ye,,,t\YVE',-., <br />CHEW, f BILLING ADDRESS <br />BUSINESS NAME A <br />N2., c-V,C -\--k ' C ,'('-.'\ R \c-_wl ,Niv-, "Icst <br />PHONE # <br />( ,-40-t) 5 VA <br />EXT. <br />HOME or MAILING ADDRESS <br />(°(Th(-\ '‘ • ;'(-"'‘ (\\t'• C\.6- <br />FAx# <br />(-"Lc) 54S. ;A.Lt s< <br />Ye CITY <br />S\ <br />STATE (L1,_\ ZIP <br />q,5-1(eLl <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 JOAQLTIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER OTHER AUTHORIZED AGENT R. <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an at the same time it is <br />rovided to me or my representative. a . . <br />. MENT TYPE OF SERVICE REQUESTED: Rpt") Pt..-/ ('(c M <br />COMMENTS: <br />t \ EiVED <br />ti&iZ ‘ ' 141\1 4 44 MAY 1 2 2009 <br />HEZI,FtVECn 2.ciiv.pe <br />' ri OEPAFQL-Arr <br />ACCEPTED BY: <br />Aid a <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: PrepAzA\ EMPLOYEE #: ,f3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c2, PIE: 2-- <br />Fee Amount: 6 '-'- Amount Paid al b — Payment Date S yy 6 <br />Payment Type Invoice # Check # IO 2__SH Received By: <br />DATE: — cPk <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003