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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F90D t�-Pov19 1 SrzaU-7t5 21S <br /> OWNERIOPERATOR S'fP ^i- 1rQ.p+�Iyyo �' f M ) KC, JOII'1 , CHECK IfBILLING ADDRESS <br /> FACILITY NAME ^ y) Dc.L-)cI L7 V< <br /> SITEADDRESS ^ .A�JG SpRCCkSLS 4-VF- NuMANTA 85336 <br /> Stree[Number Direction Street Name 11 city <br /> ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5 00 S Lo'YI¢_yuL��e, 1""oLt Jlogsry� * 21'10 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 0lea5a�tM c4 QlySg& <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (Slo) 648 3Sy S+IARANMI-F <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CO"�NTRACTOR/ SERVICE REQiJESTOR <br /> REQUESTOR fi oo -HCL't' ,E0tQTL; -DNILLONCN Q [I' <br /> - CK If BILLING DRESS I�3.I <br /> BUSINESS NPHONE# EXT. <br /> AME <br /> ..6 a 4 41,C - 3 <br /> HOME or MAILING ADDR SS FAX# <br /> s2. Dr. Sf� I <br /> Me) 3�� <br /> CITY STATE C ^ ZIP "22 <br /> BILLI1IG 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 /> APPLICANTS SIGNATU RE: a-�a& DATE: 0VO2-Jrk l j <br /> PROPERTY/BUSINESS OWNER LTJ OP ATOR/ AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization 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 provided etO�e Or <br /> my representative. % /Y <br /> TYPE OF SERVICE REQUESTED: W �+oey1EF6 <br /> COMMENTS: <br /> SAI Nd 2 Qts <br /> HE <br /> ENVIRO IN% 4L. <br /> Eiyr <br /> ACCEPTED BY: Pfr EMPLOYEE M DATE: <br /> ASSIGNED TO: a TM I f VEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed)/: SERVICE CODE: fC 7.�l"J PIE: ' V/ <br /> Fee Amount: -I I Amount Paldip, 41-). 6 5 Payment Date <br /> Payment Type Invoice# Check# gasO Received By:dW— <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />