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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Bu iness or Proper y <br />BUSINESS NAM E• <br />ZGY�� er S� S Z G I hC <br />FACILITY ID # <br />SERVICE REQUEST # <br />Pe 4 <br />a 2 CC <br />i <br />��� <br />5200-7C -I(Qf? <br />OWNER / OPERATORC <br />14 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />If BILLING ADDRESS El <br />r-THECK <br />ASSIGNED TO: ` %1 <br />EMPLOYEE #: <br />DATE: <br />FACILITY NAME <br />U V 1r✓j 1 �� <br />SERVICE CODE: 15 <br />PIE: <br />SITE D <br />IV� <br />nn <br />�/-IAve6StreetNumber <br />V Y' -(1 treet Name' v— <br />� C(` <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Received By: <br />t <br />C�6�I^G ✓` �� <br />Street Number <br />4t14aft <br />CITY <br />t ^ ( <br />C a ` <br />zip J <br />AT %- 7 r <br />PHONE #1 EXT. <br />day) `/7 <br />APN # <br />1-2 05V0-,3' <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT —7LOCATION <br />CO E <br />C <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR A <br />RJI G CHECK if BILLING ADDRESS <br />BUSINESS NAM E• <br />ZGY�� er S� S Z G I hC <br />PHONE # Ex-r. <br />HOME or MAILING ADDRE S <br />FAX # <br />a 2 CC <br />c ) <br />C. -7 <br />CITY —rla, <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 preparedthis applica ' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA nd F DERAL laws. <br />APPLICANT'S SIGNATURE: `l -tai%` DATE: 3 Z D I <br />PROPERTY / BUSINESS OWNER OPERATORk47ANAGER ❑ OTHER AUTHORIZED AGENT ❑ eS ✓) LaJ /� Qom• <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 provided to me Or <br />my representative. <br />Aw . <br />TYPE OF SERVICE REQUESTED: ��L .i : �.0 <br />R'TrM <br />COMMENTS: <br />to <br />0 03 <br />0 <br />18 <br />h, 0 tiMFC <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: ` %1 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if alre dy Completed): <br />Li <br />SERVICE CODE: 15 <br />PIE: <br />Fee Amount: q <br />Amount Pal 60 <br />Payment Date/ g <br />Payment Type <br />Invoice # <br />Check # /3 0 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />