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� II. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# f SERVICE REQUEST# <br /> Ca'F� F} Colo 7& QF, ob-n Co- r7 <br /> OWNER I OPERATOR )01©res or Fir ryz `� t o l t "' <br /> CHECK if BILLING ADORES s❑ <br /> ! 1/V / <br /> s <br /> FACILITY NAME �` �S &kff DCd �'Af'f—, <br /> I 11 J S 11 - X15337 <br /> Silt ADD L i Pe s+1 �a <br /> street NumLcr I eclr <br /> S re N e GI Zip oQe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> ' SiroelNum6er "� �� S rest <br /> CITY TE ZIP ? -3�1 <br /> PIsoNE#1 ExT. APN# LAND USE APPLICATION# <br /> I <br /> (2h 321-3U-0 <br /> PHONE 42ExT BOS DISTRICT LOCATION CODE <br /> I11 } CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR O` �t CHECK if BILLING AU4RESS <br /> PH NE# 2 Exr. <br /> BUSINESS NAME \f Q IS '� J� � <br /> FAX <br /> HOME or MAILING ADDRESS <br /> CITY V�Y ��L c + �L 1 1 ` \ STATE r A ZIP q ..7 <br /> BILLING ACKNOWLEDGEMENT; 1, the undersigned property or business owner, operator or authorized agent of same, " <br /> i acknowledge that all site and/or project specific ENVIRONMENTAL HEALT+1 DEPARTMENT hourly charges associated with this project or <br /> I 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 FEDEML laws. <br /> APPLtCANT`S SIGNATURE: DATE._ <br /> PROPERTY I BUSINESS OWNER t OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> I/APPLICANT Is not the SELLING PARI Y,proof of authorization to sign is required TI rte <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 assessment Information <br /> ( to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prkvided to me or <br /> my representative. J•r <br /> TYPE OF SERva REQUESTED: Q/4 <br /> r <br /> COMMENTS: <br /> rr JY � ?03l <br /> rH N 10!A U/eco <br /> �4LTy a�pMR�`ra�7Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: l <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: Q�_ <br /> Fee Amount: Amoun3 <br /> t Paid � a D� Payment Date <br /> Payment Type Invoice# Check# 3,90 ReceividBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />