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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />' GV <br />FACILITY ID # <br />ZAHiby <br />SERVICE REQUEST <br />/' <br />AA <br />BUSINESS NAME /Ir t'e / <br />poo <br />O W NER I OPERATOR <br />FAX #v <br />L'] <br />L <br />( ) <br />CHECK If BILLING ADDRESS <br />.FACILITY NAME <br />cA i <br />n <br />K� <br />Tcif C <br />ASSIGNED TO: wun <br />P'� <br />SITE ADDRESS °��//'A111141-- <br />EMPLOYEE #: <br />L�,�,� <br />Date Service Completed (if already completed): <br />� <br />�og <br />SM ber Direction <br />PIE: <br />01i <br />. <br />eSfr¢eTtPe <br />Payment Date <br />✓ ` <br />-Pl <br />H ME Or MAILING ADDRESS (If Different from Site Address) <br />Check # <br />?,ME4 <br />Street Number `ter r Street Name <br />CITY <br />STATE ZIP <br />G <br />PHONE #I EXT' <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2�f1�1 ���'(I (. EXT. <br />( ,iW(T IVN—A1 Ul lilt <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />' GV <br />c y <br />ZAHiby <br />COMMENTS: <br />I c,roum van <br />CHECK If BILLING A,DDlR555E�SS <br />BUSINESS NAME /Ir t'e / <br />(/j `� N/ ✓1/ <br />H ME Or MAILING ADDRESS <br />FAX #v <br />d 1 d <br />( ) <br />hormAri <br />CITY <br />STATE <br />ZIP <br />�. <br />BILLING ACKNOWLEDGEMENT: 1, 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 />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.�XDATE: l6 10 Z <br />PROPERTY I BUSINESS OWNER.L>.L.. OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ - <br />If APPLICANT I.s not the BILLING PARTY, 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 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 pr0y!'Lded to me or <br />my representative. .b �"Wyfo�, <br />TYPE OF SERVICE REQUESTED: 3 anve <br />' GV <br />c y <br />COMMENTS: <br />I c,roum van <br />� y 3�-�� I�� <br />�Uyy V <� <br />qV' 692'2 <br />y�<T <br />Hy CO 011 <br />RTCF0T <br />ACCEPTED BY: <br />hormAri <br />#: <br />DATE: 2 7 <br />ASSIGNED TO: wun <br />EMPLOYEE #: <br />DATE: Z17 <br />Date Service Completed (if already completed): <br />I <br />SERVICE CODE: <br />PIE: <br />Fee Amount: '3L11 . UO <br />Amount Paid <br />/3q !) o <br />Payment Date <br />127—/`-, <br />Payment Type <br />Invoice # <br />Check # <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />