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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 61-A SS VEN/CLE PfUZK/�/ --JS�ZC 5 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> DfAmoye r9AAI.SPokTATioA/ 4-0 1ST/C!5_ NdES- <br /> FACILITY NAME <br /> SITE ADDRESS <br /> _Street Number. Direction Sheet Name CiN `� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) O28SU 00/Y1/S /e OAP <br /> Street Number Street Name <br /> CITY [-F0 STATE CA ZIP <br /> .J\ 1. <br /> - o # <br /> ) Old <br /> PHONE# E%T. APN# LAND USE APPLICATION <br /> (701) <br /> 0 — - o0 o <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR!/ SERVICE REQUESTOR- <br /> REQUESTOR -/-�� 'wry <br /> DOA) <br /> /1 /(�S, r Pr CHECK if BILLING ADDRESS Lek <br /> BUSINESS NAME VV 'v Ci/"1 l4 / PHONE# EXT, <br /> f! C <br /> HOME or MAILING ADDRESS FAX# <br /> 4i Foy- 3 ) <br /> CIN STATE ZIP 9538 <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 appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST E And FEDER <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M XNAGER ❑ O HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of author! ation 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 i5 provided i0 pwytQf�� <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: N/TRATC 40ADIA16 APL a IrA 9 IF L e iIV�D <br /> COMMENTS: ,� tV- t(,{ k,KJ ri �!I C.Calr S MSA f"OAQUt 9 ZV X16 <br /> .sHfGCTV100411-/V-r,/ COON <br /> N I)CA 1_ <br /> ACCEPTED BY: n(f 1c� Metil/l t�Cr, O{-r.� EMPLOYEE#: DATE: ()t q <br /> ASSIGNED TO: t CI 011 I o Iu EMPLOYEE#: DATE: v 2q /4-' <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: C/ Amount Pai IS o Payment Date '7 <br /> Payment Type ✓ 1 Invoice# Check# 335 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />