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SAN JOAQUIi, ;OUNTY ENVIRONMENTAL HEALTH DF.r-ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR /� L_ �� <br /> f'i V l� �� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 35 O CARP6A1r ��e � D <br /> S�CTo 4S 2 t S' <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) o 32& 6 0 LF G R F—&JS LAS E <br /> Street Number Street Name <br /> CITY �� STATE CA ZIP ^5209 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# "' <br /> (201) -4 74- Cod 30 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �A LV f R tC^•U 9 CHECK If BILLING ADDRESS <br /> BUSINESS NAME RFl,.'A T—C-6 ^(C„G� PHONE# EXT. <br /> � Zo9 ?�•—�o �o D <br /> HOME Or MAILING ADDRESS FAX# <br /> I o32� GoLF GJ?E-r= J_S t�G c > <br /> CITY SToCIK- D N STATE GR ZIP <br /> gS20`� <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATOR �)71 i— ,'L' (,' ,K DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ElOTHER AUTHORIZED AGENT <br /> If APPLICANT IS not the BILLING PARTY.Proof of authorization to sigh 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVE <br /> APR 16 20 <br /> N jOA11111N COV <br /> FlIme TAI-"TACCEPTED BY EMPLOYEE#: DATE: <br /> ASSIGNED TO: C U EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: � PIE:,�Q <br /> Fee Amount: �3�. �] Amount Paid U Payment Date <br /> Payment Type ^ Invoice# Check# ` (DU& Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />