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N)G �n F �C U/ �Fpovg <br /> SAN dOAQUiN U NVIRONMENTAL HEALTH ARTMENT <br /> RE�b- - VICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> JUN 28 2011 �7q9 S2�(oLSb'O <br /> OWNER OPERATOR EwRONMENTAL HEALTH CHECK if BILLING ADDRESS❑ <br /> pr.1 3�r �"� ER{JPFT�L in w,sS-r Uys rwaz� <br /> FACIUTYNAME <br /> SITE ADDRESS I .. S f'� 5'-j�C1�'Ca7*� <br /> 1533 Creel Num er Direction Street Name Ci Zi eotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> � /Street Number Street Name <br /> CITY �" STATE ZIP <br /> ,J 15- <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (2041 4L7 — (ilv71 <br /> PHONE#Z En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> •-��}� CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOipwS Bre C��� CHECK If BILLING ADDRESS <br /> ta <br /> 6.4 &+-£y � <br /> PHONE If Ems' <br /> BUSINESS NAME £�, R �x� 3` -� +Pl-)J <br /> HOME Or MAILING ADDRESS <br /> FAx# Z <br /> Z3 ti� M'%C csa <br /> CITY L—ozY STATEZIP 195-24Y) <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 /> 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, S TE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATrE��:�� <br /> PROPERTY/BUSINESS OWNER❑ OP R/MANAGER ❑ OTHER AUTHORIZED AGENT tt9- <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> SHe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the pro 1rt+ th <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environme a ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at1t11[6a0TjttTell is <br /> provided to me or my representative. ..ltUu�t\\ L <br /> SAN UNT <br /> ENVIRONMENTAL <br /> TYPE OF SERVICE REQUESTED: <br /> ComOI(i/'31'�uPsi116 pq/MnNt 1r£A4k P £:Fcawt C£SY �otr. ra t=nuur y t'• £ �tsQ a <br /> � � "atL DGrtvsr7e onr '4' O tSSEt_ TnT-AL, £A�£.«Pr.�y Y�£PAswS CDA a d <br /> u(,f Z.V-140* IZ-E'fiO�Bo # 2£Pa./k.F� wx'M VM S �{�7 LD -'Z+00 i EA*- <br /> D ;Tse-Mr- SSn-cri 41 6Clo aiSt 9 <br /> ACCEPTED BY: ��� EMPLOYEE#: 9D DATE: ((J !� <br /> ASSIGNED TO: ���� EMPLOYEE#: 776d DATE: � 40 /� <br /> Date Service Completed (if already completed): SERVICE CODE: / L/ PIE: a300 <br /> Fee Amount:&&O Op Amount Pai t-OIL Payment Date o2Ii— <br /> Payment Type Invoice# Check#,.2, � eceiv d By: <br /> EHD SR FORM(Golden Rad) <br /> REVISED 11/1SED 1111 / ; <br /> 712003 IT' <br />