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SAN JOA'4 ,N COUNTY ENVIRONMENTAL HEALThr JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U,GD VUUD T rUGI� SP UU O2� <br /> OWNER OPERATOR <br /> ' CHECK If BILLING ADDRESS <br /> FACILITY NAME t-c?f' <br /> f ree um er DIrecllon CI Z o e <br /> HOME O[M91LING ADDS (If Different from Site ` ' <br /> C.I-�`✓1 iL/l`" I-'qJ- (-'Y v, Street Number Street Name <br /> CITY 'S+CC /r —0 V-) STATE ZIP <br /> PHONE#1 � V EXT. APN# LAND USE APPLICATION# <br /> (14)10(p Qbo(s <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (2A 552) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ganbel -� . 12plmrrl?� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEI /*1G�` pPHONE# E . <br /> HOME or MAILING ADDRESS ✓ /t n� -�1 ' /^ r k, / FAX# ) <br /> CITY � V STATE 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,STATE30-FEDERAL laws. 1QQ <br /> APPLICANT'S SIGNATURE: l/ DATE:01 <br /> PROPERTY I BUSINESS OWNER I/7 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign IS required Tirle <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: FOOD ?\"W 0 ] Cvr ee• <br /> COMMENTS: ��n, ' 1 TUI (1 T 1 r � ED <br /> vV�f I w I �J v AUG 0 8 ?Ofd <br /> 8AN UOAQUIIV COU <br /> Nrr <br /> ACCEPTED BY: �Y/� I M 9-&� EMPLOYEE#: DATE: X rC <br /> ASSIGNED TO: N EMPLOYEE III: DATE: U V <br /> Date Service Completed, (if already completed): SERVICE CODE: a3 PIE: , <br /> IL <br /> Fee Amount: 5 �0 Amount I<-/FO& bZ) Payment Date 8/ -7 <br /> Payment Type 'SA' Invoice# Check# /���9� Received By: ix <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />