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e ' <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 14 (z� :.7� �l ✓� � CHECK If BILLING ADDRESS <br /> n FACILITY NAME ✓V <br /> SITEADDRV,-y DR, f)t !/ ItC/ C Al' <br /> �4t q Street Number Direction tree Na e J city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /O�'' <br /> 52 Street Number Street Name <br /> CITY "Z <br /> / STATE ZIP t -5-Lo Y <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 4160 2 $7 (I 5-. 3 oo3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 431Z- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> U/ CHECK If BILLING ADDRESS <br /> V'l.. r <br /> BUSINESS NAMEEFAX <br /> # EXT. <br /> PEC c 479-dZ89HOME or MAILING ADDRES , ?43- Sao <br /> CITYC 7 �i_(�,t ' A STATE 04 . ZIP C�G 2Q� <br /> BILLING ACKNOWLEDGEMENT: I, the l 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 application a d that the w e performed will be one in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TATE a EDERAL <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It 13'pjQY jj� me or <br /> my representative. AT�UIgNT <br /> TYPE OF SERVICE REQUESTED: yT p ® <br /> COMMENTS: 201+4 <br /> SAN JOAQUIN COON <br /> ENVIROMENTAlL <br /> HE DEPARTME <br /> NrT <br /> ACCEPTED BY: 13 I `C U Lt EMPLOYEE#: DATE' t I <br /> ASSIGNED TO: ,(7 ����� EMPLOYEE#: DATE: <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: Gt D PIE: <br /> Fee Amount: Loi Amount Pai3 l a �D Payment Date 10 1 �j - <br /> Payment Type f'� Invoice# Ch C�ti 083 6B(4_1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 3qV <br />