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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IPEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> Maxr)<d (0 .ple- <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> N015 Yang <br /> FACILITY NAME xJ /llc?1IG 1/ Jaifn pelr[.l o'-s F'04 <br /> SITE ADDRESS !Nction I�t1 40'1 t^��/V SfGC.Ic�Gn 9S Z cs <br /> 5 SC3 Street Number DireStreet Name Ci(V Zip Code <br /> HOME Or MAILING ADDRES If Different from Site Address) I <br /> 100 Street Number reQG� Street Name <br /> CITY STATE ZIP <br /> Scc eft,t�7 GtZ�a C 14 Ori V 31 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#z EXT. BO$DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J ` PHONE# EXT. <br /> Oe.(JdeW (407 317 ' Iqsri' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �cL 4,^6T r�7 ei 2�0 STATE ZIW;5 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andlor 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY!BUSINESS OWNER Sl' OPERATOR I AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 assessmenta_ tion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time It Is provi <br /> my representative. fqr <br /> TYPE OF SERVICE REQUESTED: . <br /> COMMENTS: <br /> �do� Oo 19 <br /> 7yO- �E f, <br /> T <br /> ACCEPTED BY: 1,J A� oyzeA/1,o EMPLOYEE M DATE: <br /> �*[. C� <br /> ASSIGNED TO: II Y lh� 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: > <br /> Fee Amount: �(�'} Amount Pae 1S�2 QD Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />