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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pr:11/ FACILITY ID# SERVICE REQUEST# <br /> u <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME U L fyr,w%-Q/ <br /> SITEADDRESS /S3 _ I Ii/ fih ��c� �v�G� ���� <br /> Street Number Direction l .et Name Ci 2i Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO rdt CHECK If BILLING ADDRESS <br /> BUSINESS NAME v,(� PHONE# ExT' <br /> HOME Or MAILING ADDRFAX# <br /> � ESS LO /CeA,.� (zcq , 3coa'- Is <br /> CITY LLLC/ STATE L+ '^ zip SSZA-LU <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 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: _ — DATES: <br /> PROPERTY/BUSI N ESS OWN FR OPERATOR/MANAGER ❑ OTHERAUTHORizEDAGEMI'E /) 0H44e- C/t_ <br /> IfAPPLICANT is not the BILLING PART r Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> infortnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: U✓� 0 — — <br /> COMMENTS: 20V <br /> F E8 3 cook FEB 19 2008 <br /> S�sopJa ilgot& ,"ENVIRQNhtEPIT HEALTH <br /> NTN DEPP <br /> ACCEPTED BY: EMPLOYEE#: qDate <br /> : <br /> ASSIGNED TO: EMPLOYEE#: : <br /> Date Service Completed (if already completed): SERVICE CODEPIE: <br /> Fee Amount: 41 Amount Paid apt` —� Pa3 f Q <br /> Payment Type Invoice# Check# lea Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />