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SAN J0AQUIhIPOUNTY ENVIRONMENTAL HEALTH D•RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property a FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR,J <br /> T�N� L{�J CHECK If BILLING ADDRESS� <br /> FACILITY NAME �./ _ //� '/ �o D'/ ll ✓I Q ` <br /> Ul Gi1"q r// / . r M <br /> SITE ADDRESS �L/ y� �c936- <br /> Street Number oiret[ion i [reef NameG , I C 1. �T zip Cotle t, <br /> HOME Or MAILING8z ESS ADDR (if Different from Site Address) <br /> /L� i'n icx ��e <br /> �rU 7 V!r Stree[Number aSo7 r Street Name OT� <br /> CITY 714�y E..0 f STATE„A ZIP cT5r3� <br /> PHONEE#1 /`T EXT. APN# LAND USE APPLICATION# J (' <br /> PHONE#2 EXT. BOSS�DIS`TRIyT LOCATION CODE <br /> ( ) `N <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 'T/d�0 �/�'� / 1 t�T• CHECK if BILLING ADDRESS <br /> V G_ tC _�/f l.� -J._J� ' f EXT. <br /> BUSINESS NAM PHONE /�' C �qI r��� <br /> HOME or MA2%G ADDR t7 �A — �( FAX <br /> -// J /,r ( ) <br /> CITY 414 1!14 <br /> ^STATE ` In zip Cj <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 JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR�E�._—S DATE: 9 -2-LI <br /> I <br /> PROPERTY/BUSINESS OWNER.CJ OPERATOR/MANAGER ❑ OTHER AUTHO DAGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof of auth0rization 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 povided to me or <br /> my representative. `� AY <br /> TYPE OF SERVICE REQUESTED: S' O L- 1 V f� �+E�I <br /> COMMENTS: P-2 ,/ <br /> aAan Q le, O I-- %J0a , 20/5 <br /> hE CNHt R OEpAq MFNT <br /> ACCEPTED BY: a (—n EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: V j <br /> Date Service Completed (if already Completed): SERVICE CODE: N I PIE: <br /> Fee Amount: i Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />