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OA IIIN COUNTY ENVIItONMENTAL HEALTHARTMENT <br /> SAN J 4 <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> e' 7 <br /> OWNER/OPERATOR ^�^ ` CHECK It BILLING ADDRESS <br /> J\U� <br /> FACILITY NAME ` <br /> SfrE ADDRESS �\ C _ �e v.-w.v'� l <br /> SVeet Name Ci Z Cade <br /> Street Number Direction �� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �SS 0� SVeet Number tree[Name <br /> $TATE _ ^F-1 ZIP <br /> m (JgSays <br /> C <br /> S oc�l , <br /> APN# <br /> 77// LAND USE APPLICATION# <br /> PHONE#1 Exr. 2 ;T _ <br /> E� BOS DISTRICT LOCATION CODE <br /> PHONE#2 Z- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR CHECK If BILLING ADDRESS Lei <br /> PHONE � <br /> # <br /> BUSINESS NAME _ 1 3-13 <br /> FAX# <br /> HOME Or MAILING ADDRESS ) -( W1 3 <br /> 00 Lm e. <br /> Cm <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 ENVD2ONNIENCAL 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 lawns. ,r <br /> APPLICANT'S SIGNATURE: �,y/,,�V✓'oL � DATE: ��' ��— 0�(y r) <br /> PROPERTY/BUSiNESS OWNER LJ OPERATOR/INI. NAGER 13 OTHER AUTHORIZED AGENT 5I r� -n\ ^r• U `c�C I <br /> If APPLICANT is not the BILL/NG PAR Ty,proof ojauthori:.ation to sign is required <br /> Tide <br /> AUTHORIZATION TO RELEASE INFOIUMATION: 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. <br /> TYPE OF SERVICE REODESTm: LAS -7- C`)/ T <br /> COMMENTS: . . !-_ S CT 2 1 2008 <br /> I r' 108 1, AlVW'l-ZOl fNp)y <br /> Np <br /> EMPLOYEE I. 3,7 DATE: <br /> #PaymentTypRet.,� <br /> �..L i \. t F� <br /> ^ t �7 EMPLOYEE#: 14? y DATE' C O 2.[.` -`L 1mpleted (if already completed): <br /> SERIACECODE: /�j� P 1 E: ��p <br /> qPayment Date`��S/ S "% Amount Paid :� 9 <br /> I' Invoice# Check# 3� t 1 C Received By: V-- . <br /> - - SR FORM(Golden Rod) <br /> EHD 4&02-025 -- - <br /> REVISED 11/1712003 <br />