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SAN JOAQU" COUNTY ENVIRONMENTAL HEALq -DEPARTMENT <br /> Sftw SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C-,aao 4,4�0rn 7�-Fg-& S3,5 UC <br /> OWNER/OPERATOR <br /> �. •t� O ;� t,� CHECK If BILLING ADDRESS <br /> FACILITY NAME tt�_�\,� <br /> SITE ADDRESS 18�gN't v.L. '�hG.A V.� ' �r-Z+on 053Zfo <br /> Street Number I Direction Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EVT. APN tt (�3- 3Z o- z3 LAND USE APPLICATION# <br /> ( ) ! <br /> PHONE#2 EXT. BOS DISTRICT / LOCATIO�1 CODE <br /> ( ) r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ly-1 N T�l, A, ' S�n�(�(„l CHECK if BILLING ADDRESS <br /> BUSINESS NAME PN E# Ext <br /> �Z SV,%Vktf, NA0. o11 OU lQ <br /> HOME or MAILING ADDRESS F # <br /> 7�p.pt x q3_3 (11(p) 391- 45 <br /> CITY STATE Ch ZIP q5bql <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 <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, STATE and FEDERAL`laws. ? n <br /> APPLICANT'S SIGNATURE: lk DATE: ✓I 1�/oD <br /> —Tr <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLtCANT is not the BILLING PARTY proojof authorization to sign is required Title <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 and at the same time it is <br /> provided to me or my representative. _ �f' <br /> TYPE OF SERVICE REQUESTED: ST Y[-�I I�-r+ t T CE(v E'D <br /> DDMI, � C1 v i u MAR 14 2008 <br /> MAP, 1 4 [OOH SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> HEALTH <br /> ACCEPTED BV: ` _l`� EMPLOYEE#: d 3 Z/ DATE: _•3 t� <br /> ASSIGNEDTO: v/p N f lk-LL-r- EMPLOYEE#: O '3 / 7 DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 'Ct� PIE: <br /> Fee Amount: �Gt Amount Paid 1P.2-17D D I Payment Date 3 (it 1 O 6 <br /> Payment Type Invoice# Check# '(o C-7Received By: <br /> EHD 48-02-025 SR FORM(Gol nig R9{D <br /> GFVICCn 1vi7nnm Q�J/ <br />