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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QPEAcl f.4L4-o6/ LAA/ID sce�a73 o <br /> OWNER/OPERATOR <br /> /"R ' �Ir A/.JiIT=/RI-R CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS gy S3 L/NAVE RoA4D TAey 97304 <br /> Street NumScr Dlrectim, Street Name Ci Zip Code <br /> HOME Or MAILIN@ ADDRESS (If Different from Site Address) 3St3/Z I /? /TEKE V DR I V E <br /> Street Number 90AtStreet Name <br /> CITY STATE0A <br /> ZIP 95847 <br /> GfN/Otil_ClT 7/ <br /> PHONE#1 Ezc APN# LAND USE APPLICATION# <br /> V09) �3S 2178 20- b0-.23 oA4 - &000ay <br /> PHONE#2 En. BOS DISTRICT LO CATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RErQUESTOR CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# Ems' <br /> E dG8 -I <br /> HOME or MAILII IG ADDRESS FAX# <br /> , 0. Tao 3 (Z#9) 6t 9- If-- <br /> CITY -- L STATE C,t ZIP r <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 have prepared this ap catiun and th the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouraT+Ordinance Codes, Standards, S and FED A aws. t <br /> APPLICANT'S SIGNATURE: DATE: �Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ THER AUTHORIZED AGENT ' <br /> If APPLICANT is not the BILLING PARTY Proof Of aut to <br /> 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 to me or <br /> my representative. - <br /> TYPE OF SERVICE REQUESTED' SGR FACS _Lfa0Su2Fi4CE COAI7-A1 1A/ATIVAI /2EP02r/e rCV/Et✓ <br /> COMMENTS: �2/�6 ZIa I( � PAYMENT <br /> RF!^E9®fEn <br /> � /�-- DEC L 9 201,l <br /> j SAN JOAQUIN COUNTY <br /> ___ ------- ENVIB MENTAL-- <br /> ACCEPTED B ' — EMPLOYEE#: HEALT UPARTIIQENT <br /> ASSIGNED TO: Tawsyo#v S` EMPLOYEE#: I DATE: — <br /> Date Service Completed (if already completed): SERVICE CODE: PIE D <br /> Fee Amount: Amount Paid 6 0, D Payment Date /a a 57 <br /> Payment TypeGInvoice# 3 3 S Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />