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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �c S QU t � ac�Lll S(�00 <br /> 7%g3 <br /> OWNER/OPERATOR 1 <br /> CHECK If BILLING AODRESSO <br /> FACILITY NAME <br /> SITEADDRESS QV rtlr�\}t 1f C �-�/� _ I�\ C ^fU <br /> Str Number Direction l 10 Skde e 1 \ �-/ � � kcc' O`kV IJC`ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY ^ STATE zip <br /> PHONE#1 Y EI`T APN# LAND USE APPLICATION# <br /> (1°A) 3-1 3-r� gt 6 <br /> PHONE#2 D/ _.� /O EIR' BOS DISTRIICCTDISTRICT,!,,, LOCATION CODE <br /> ori b C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,.1t (`� ^1 CHECK If BILLING ADDRES <br /> BUSINESS NAME W O\V S\' 1'12 P N # �-r Exr. <br /> V V` a / <br /> HOME or MAILING ADDRESS FAX# <br /> A 2 MGSS(r�loC (Z ( , <br /> CITY 1 V UCTN \ STATE 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 identifi d on this form. <br /> also certify that I have prepared this appl' 'ontEDE <br /> n that thew rk to be ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA L Is <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER19- OPERATOR/ A AGER 13 OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PAR ,Proof of authorization t0 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 iltinformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Samfile Or <br /> my representative. •TF `S� <br /> TYPE OF SERVICE REQUESTED: � la.1�2 N_ A <br /> COMMENTS: C <br /> ✓O <br /> 'yo, <br /> N9�� <br /> F'vT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 0 <br /> 9 <br /> ASSIGNED TO: N EMPLOYEE M DATE: a' <br /> Date Service Completed (if already completed): SERVICE CODE: 2 PIE: <br /> Q <br /> Fee Amount: 4p2& Amount Pai / LrS6.6 D Payment Date S V- <br /> Payment Type L, Invoice# Check# <br /> b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />