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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESST# <br /> OWNER I OPERATOR <br /> ' CHECK If BILLING ADDRESS <br /> 2. <br /> FACILITY ME } TVAJ _ C ( L I RI O D O <br /> SITE ADDRESS �(\)'1 on <br /> �Jc S"� C �1 gsao cp <br /> I Street Number Direction I o I /Stree[Ne CI Zip Code <br /> HOME or MAILING ADDRESS (IifDifferent from Site Address) <br /> /LD_ Street Number Street Name <br /> CITUL STATE ZIP —� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# \L <br /> (010(l) g0$- I % 96 b) �- <br /> PHONE42 ExT. BOS DISTRICT LOCATION ODE <br /> Go) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /e ' �,l� !�-L <br /> NG <br /> Y �/ CHECK If BILLIADORES <br /> BUSINESS NAMEPHONE# Ell. <br /> Q�nnt(2 C-06 " wy gb% <br /> HOME Or MAILING ADDRESS1 1 ��h (A%# ) <br /> CITY / L � STATE ZIP <br /> Ift <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized•�agent loJf same, <br /> acknowledge <br /> ' <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 /> 1 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, ATE and FEDERAL I- '1 <br /> APPLICANT'S SIGNATURE: DATE: o <br /> PROPERTY I BUSINESS OWNER) P RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the LLING PARTY,/!roof of authorization to Sign IS required Tide <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 assessmentI pinformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: [) <br /> COMMENTS: Ir <br /> n DEC 2 6 201 <br /> 'tel Q r1c�� D O Wl I"er�J I� L� • SAN JOAQUIN COU 4TY <br /> ENVIRONMENT <br /> ^ 1 - HEALTH DEPARTM NT <br /> ACCEPTED BY: \n/f1 EMPLOYEE M DATE: / 2 — '�47 .i <br /> ASSIGNED TO: EMPLOYEE DATE: 42 /Gl - /-7 <br /> Date Service Completed (if already completed): SERVICE CODE: V PIE: o/�-( �3 <br /> Fee Amount: 2 Amount Paid �C2•QJ Payment Date 12_ Zt. 1 <br /> Payment Type Invoice# Check# Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />