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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> W ER/OPERATOR <br /> NAUV ` (1 _ y ` eUl� <br /> FACILITY NAME` vy CHECK If BILLING ADDRESS <br /> `� f Y <br /> SITE ADDRESS f2, 1r J 0Ai y'1 YII�r <br /> street Number Direction Street Name Cil ZI Code <br /> HOME Or MAILING ADDRESS If Different from Site Address) <br /> c Street Number Streot Name <br /> CITY STATE ZIP <br /> r o Q{ . G <br /> PHONE#t EXi APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� v q 1 <br /> 1 It fi ✓(T� � LFV t/1..�' O 1 �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME t"IY1.1✓� ll.. 1 `• , \\\\ ; P N ' ^ EXT. <br /> 10 <br /> HOME or MAILING ADDRESS V FAX# V/ J <br /> IPI S (-� rVl vV✓t c ) <br /> CITY STATE n^ ZIP <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,Standards, STATE and FEDERAL laws. f (� <br /> APPLICANT'S SIGNATURE: (SIV Ind h- F'i`r eo\cl DATE: IO C(`— V <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY proof of authorization f0 sign is required 7'if(e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> '"�� <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same d t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: d I G `� /`, R <br /> COMMENTS: 10 -Q <br /> (00 SAEINONMENT LN <br /> FiF.WA DEPARTME <br /> ACCEPTED BY: - mol /Jnn J EMPLOYEE#: � �e� DATE: <br /> ASSIGNED TO: S, ^ 1/IW r��,� EMPLOYEE#: w t� DATE: I J-may•('� <br /> Date Service Completed (if already eorrtpleted): SERVICE CODE: <br /> Fee Amount: it I52 Amount Paid V2— Payment Date �tS 6L. <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />