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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CS%A �PM1" z ( 0 ( c)V,06 Q�q <br /> OWNER/OPERATOR 14 <br /> • n L,.P- LCHECK if BILLING ADORE55O <br /> FACILITY NAME 4 `&2 <br /> `� � .J�T5A.---- <br /> SITE ADDRESS � - a v _ Cn � l .K +/ / n5;z l() <br /> [ et Number Direction '`-Str t Name `-G�i lJ v` M Zi Co7tleV <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> (z 3 - 2 ��-� 010' 'L- 55t'-10 <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> nb <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /) or,q '-(�( <br /> 'C vV r ( "1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME f h PHONE# <br /> L_e064 -5A <br /> (pZ�iL <br /> HOME or MAILING ADDRE FAX* <br /> CITY (/o �- TAE ZIP d 0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business o ner, 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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: —/ �L DATE: <br /> PROPERTY I BU SIN ESS OWNER 11 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 Is prided to me or <br /> my representative. \/ <br /> TYPE OF SERVICE REQUESTED: 11A Y `c <br /> ZA( <br /> COMMENTS: ✓(/A' ( `O <br /> y NOI As.COT UO,�' <br /> M <br /> ACCEPTED BY: � rO EMPLOYEE#: DATE: <br /> AssIGNEDTO: l L3�Tit.QEMPLOYEE#: DATE:C/I <br /> Date Service Completed (if already completed): SERVICE CODE:/ I E:t 'L <br /> Fee Amount: - Amount Paid T Payment Date 1 S h <br /> Payment Type C Invoice# Check# �' n ^'' Received By: 015 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />