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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> esc4u vcc �ff�D02�5(2� <br /> OWNER I OPERATOR I I p <br /> CHECK If BILLING AODRE55O <br /> FACILITY NAME <br /> SITE ADDRESS952-0 <br /> Street t(1 tuber Direction t Sheet Nama .JT�t�LCI <br /> zipC tl <br /> HOME Or MAID/prl'G ADDRESS Yf Diffe/r/�f/t�t fro-r{p�ittee Address) <br /> 2 r`r S \t4 ri('A- ` L V Street Number Street Name <br /> CITY <br /> -5L�L+OV $TATE ZIP <br /> PHONE#1 ` ET. APN# LAND USE APPLICATION# <br /> R 3 2- FfOd <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` ( f r1}�.a1 <br /> CHECK IT BILLING ADDRESS LV <br /> BUSINESS NAME _ EIT. <br /> r ( �t3 - 00 <br /> HOM or MAILI ADDRESS f <br /> FAx <br /> ( ) <br /> CITYTATE zip <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 applic ' nd that a rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S and FEo <br /> APPLICANT'S SIGNATUR DATE: L Z 27 I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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, 1, 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 assess Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time it Is p` it 71 <br /> hw <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: rood C4rSvlf"bo <br /> COMMENTS: 'AN JIENVIROIWg <br /> COU TyTg <br /> r <br /> NE <br /> ACCEPTED BY: ���I 1111 111 l x I� k/u�l' EMPLOYEE#: DATE: Z -2/1 <br /> ASSIGNED TO: �I�I ���I r -t/ EMPLOYEE#: DATE: I r� /u <br /> Date Service Completed (if already completed): SERVICE CODE: U(.dLCi I <br /> PIE: <br /> Fee Amount: I 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 />