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SAN JOAQW.. COUNTY ENVIRONMENTAL HEALTH bGPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T.# <br /> tvht,i le. �464 VWdo✓ eco C5 II` (lel/V <br /> OWNER I PERATOR <br /> L6L r(ti CHECK If BILLING ADDRESS <br /> FACILITY NAME V` at'd D <br /> SITE ADDRESS I(UD \�In G�VdS IJIV�- SCAC vc-L-Pti,j-ri <br /> Street Number Directlon I cityZI Cotle <br /> HOME Or MAILING ADDRESS (Ii Different from Site Address) (' 1-- <br /> 3) Street Number !�, J`I Street Name <br /> CITY iv . 1+15L1�.,�LIs ST!),TEA ' ZpP 5- G <br /> PHONE#1 ✓ EXr. APN# - LAND USE APPLICATION# <br /> -- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 16) 223 -631 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR v.e ' I V1� Ce LG17✓(1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME �5PHONE# EXT. <br /> HOME or MAILING ADDRESS _ FAX# <br /> CITY N I IC In 15 STATE C ,[)_, ZIP Q �/ / G <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_aDd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S A E EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: l �I <br /> PROPERTY BUSINESS OVINE OPERATOR I MANAGER ❑ 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, 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 prov�Gbt}�me or <br /> my representative. A Pki <br /> TYPE OF SERVICE REQUESTED: V I n S <br /> COMMENTS: ,� 1 T 1 <br /> J p 20 <br /> I C� ! Z 7 T dOAQUINO <br /> tab rca 8 � rna% ( f Ca r» `�"oePCAlOUN-y <br /> "M N <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: I© F Il _ i I / <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: t,�� <br /> Fee Amount: G.JZCN Amount Paid lS�,U U Payment Date 1%11-7 <br /> Payment Type Invoice# Check# /j�13 Received By!?O <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />