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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I OWNER i OPERATOR J� — t'7,7/) —�-- --� ��I <br /> {-� J�/c/vI {'/F �' p©G�,C,,,,�,,L,QY �✓r ;�� ',HEC✓if Bit.LJNG;1,RF_r3 <br /> FACILITY NAME �///'1 ,/���'l, ✓l t lx.C. �iU,l N�'b/_�SG/ � �C l�t '�_ �vU'A1�5�� <br /> SITE ADDRESS <br /> Hor _ r MAIN a hODRES (1 ren[ " i Siff Ad .res <br /> CITY ��I✓�/" -�., — STATE — ZIF <br /> PI<oIV $I EA* APN# LANr Us; "'C' # <br /> P HON,97 — —_ Cr1=1_rR,Lr II LO..A[ION C,DIE <br /> REL iF�,T �(��� T �r �`� G�Feit L� – r-- --- <br /> _ Mlz-. Mr'�r � 51,.L(/g�•..ICCK IT li,.11NG A0DRE55® <br /> BUSINESS NAME ,,,�]` _�., 1 PHONE �7/ /t r _— . E>:T. <br /> I AME or Mf !! ;ADDRESS — <br /> _ <br /> CITY 1 �D% ,•.,�� ySTTAATEE"� cA ZIP <br /> — IN l —6-ic-''mss-Csbfr-v--+l` v <br /> BILLING ACKNOWLEDGEMENT: I the undersigned property or husines owner, o;[e.-t)r us authorized agent of same, <br /> ackDOwedge that all site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly ch-ges associated with this project or <br /> activity will be billed to me or my b5.,,.'A <br /> identified on this ft <br /> I also certify that I have prepared cation and that the edormetl will be done n accordance with all SAN JonnulN <br /> CouNTY Ordinance Codes.Standar nd FEa'AL la• <br /> APPLICANT'S SIGNATURE: — _ DATE. _ { <br /> PROPERTY/BUSINESS OWNER❑ OR/MANAGER ❑ OTHER AUT HnR¢ED AGENT <br /> if APPL'LANT is not the Eix lllG PARK,pro f of authorization to sign is requil Tirfe <br /> AUTHORIZATION fl RELEASE INFOPMATION. When applicable, I, the owne x operator of the property Iceated at the above <br /> site address, hereby authorize the release of any and all results,geotechnical da.a 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 tti 1P or <br /> my lopresentative. 4 <br /> TrPE OF SERVICE P_QUESTED: _i(JllVl �j —r-�, jf+C p,�i•.y r' <br /> CONVENTS: !✓l/,�il] O v<� <br /> Hf EN�R�`1Fk q�,N� <br /> - - – -- <br /> ACC __Fi" )6Y: - — -_ � f 1PLOYEE# DATE: Q 2 I[n <br /> ASSIGNED TO: W rV l EMPLOYEE#: -- DATE: <br /> Dategel -2 Completed t,falready cot pletedyj SERVICE CODE: PIF: I <br /> PF9eAmunt: `��D=(,� AmoNm Pa 3��,jj(� FaymentD�te L -e I Invoice# Check# I �� Received By: <br /> EHD 48-02-025 I/ Il!/'�(�'�'�(i �� T To SR FORM(('oitlen Rod) <br /> 07/17/08 <br /> ado 5�1 (P9 <br /> t <br />