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w SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IID# SERVICE REQUEST# <br /> D ©o o C!'-(1 TZ7 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Fooz LL 1�p /LL ' r <br /> SITE ADDRESS /I f Pp�/�V�R`� �I ��/V q ,�3b <br /> Street Number Dire Street Name citvC e <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 /> ( 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME LF6S�N �C PHON� EXT. <br /> HOME or MAILING ADDR SS I [FAX# <br /> CITY &a/— " STATE ZIP ad <br /> AMBILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvmONMENTAL 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:_ DATE: ��� u Z � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13OTHER AUTHORUZD AGENT❑ (amAV 7t[/�&,n <br /> IfAPPL7CANT is not theBmLiNGPARTY.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 <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: s vi st-re �J 11 l4H 1 � <br /> COMMENTS: n 6Z <br /> JUN Q 3 2009 <br /> ENVIRONMENT HE&TH <br /> p,ER&a)VSERV'l'! <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: q-( DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z Q') P/E: <br /> Fee Amount: �S '" ,�,zo, � ount Paid ffi�3S; � � Payor✓ant <br /> Payment Type Invoice# Check# Q �l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17!2003 <br />