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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQEST# <br /> ab <br /> 50 1] <br /> 014�41HR/0PER!;7 R <br /> r , `^I �- CHECK If BILLING ADDRESS <br /> FACILITY NAME/T'Q\l\vU•1�� nr^YF �//r��� <br /> SITE pDRESS�� cJLu�Cecq C—T-ei <br /> �--�U StreetNumber Direction I\L ���SHeet Na a CI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> ( U Street Number Street Name <br /> C C STATE ZIP <br /> C 1c C-� <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> TMS 0 -OQ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE STORE <br /> CHECK It BILLING ADDRESSM <br /> BU_ ES SAM � Ppq # <br /> Ez <br /> HOME Or MAILING A//DD��RESS I1, FAX# <br /> UCI-L l ( ) <br /> CI STATE�� ZIP 7[/ <br /> o Vc. l <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledgb 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 prepare th applicationand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stan ar STATE nd RAL laws. ,Ire- / <br /> APPLICANT'S SIGNATUyRDATE: <br /> PROPERTY I BUSINESS OWNERa OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ WtCt'-K�c 4(,14.4k.4 '2�f <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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/sit assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same tlmliy�grovided tome or <br /> my representative. N 11 <br /> TYPE OF SERVICE REQUESTED: �(X)d ('0(?, '*t O� 7 'V <br /> COMMENTS: r_ U ✓ < 8 �O// <br /> n600(� h44DFPgRlr� �Y <br /> UCi -� I��J�X J MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE:g, �/C/-/ <br /> ASSIGNED TO: -mac. EMPLOYEE#: DATE:�j_ v�CyO. %7 <br /> Date Service Completed 4h already completed): SERVICE CODE: U SPIE: f�(�,� <br /> Fee Amount: -G,. tx Amount Pai l� Payment Date g`2ei�—1 <br /> Payment Type ✓ Invoice# Check# t ReceiJed/By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />