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SAN JOAQUI•OUNTY ENVIRONMENTAL HEALTH DEPARTMENT ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C� AS S c W L0142ky-2-- ,S f U w,63-o <br /> OWNER/OPERATOR -Rln k Com(�,` <br /> l� CHECK If BILLING ADDRESS <br /> FACILITY NAME T�'` `n <br /> SITE ADDRESS I �5-o i �� T�� �- � �i npV1 �S- 4�P <br /> Street Number Direction Street Name Cit Zi Code <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -e-U L "kQ CHECK If BILLING ADDRESS <br /> BUSINESS NAME ��N I t ^W fT .,jv� I� � l��� �VLC' PH�D� Exr. <br /> HOME or MAILING ADDRESS Jct`tel l(' i FAX# <br /> bU Q vi-til /���� (4 I V) �(3- b Oak <br /> CITY „t©%4— STATE CA zip Q SII 'L <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 <br /> or 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �, .� Vii,f ;.i--g_a, <br /> C�c-t L�.(J r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT P(1u('L(0-,kC-e �C�� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: q 1'11/�LC <br /> COMMENTS: V`.3 C &\ &' 'S 0 KA- 31uk 57 V <br /> SANN0 9 2006 <br /> EV1R�USN CC <br /> HEALTH D PAENTAL lY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE C DE: / ,79) P,E:� Q <br /> Fee Amount: Amount Paid lPayment Date S <br /> Payment Type Invoice# Check# Received By: C' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />