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T` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oh('L f� T--a ' l 2w <br /> OWNER I OPERATOR <br /> I tVA (-" �� „�O CHECK If BILLING AODRESSIJ <br /> FACILITY NAMEvls �S1ah C V-1 � 1 <br /> SITE <br /> ADDRESS _ t_ I S tv _i !�. _ + Ci sT 11 <br /> I V`✓ Street Number Direelion UTGlY7it Street me C� �(.• CI 't•� ,Z16Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address)E5 I <br /> Street Number C'I Lpl�l l• Silre�e(�Na�Z <br /> CITY o/(/,Ct A iY'li- 4 ' 3„ $l�E <br /> PHONE#) EKT. APN# LAND USE APPLICATION# <br /> 01w `iq3—913 <br /> PgoilE'2 ^�— y <br /> EXT. BOS DISTRICT LOCATION CODE <br /> l(��lil CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR `� i1 ' Hqp CHECK if BILLING ADDRESS <br /> I/ <br /> BUSINESS NAME _ t Oils Y�1/5t�;`i�\�-`0 G wt lI P IIE# O p 1 EC1 - 34 <br /> EZT. <br /> HOME or MAILwo ADDRESS FAII# <br /> 51 KZ�So C�r�1� 1 ( ) <br /> CITY C' �. Y� L STATECK ZIP Cl'moi :;:N3 <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 /> 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: �7'ZI IW <br /> Irl PROPERTY BUSINESS OWNER lEU OPERATOR I MANA R ❑ OTHER AUTHORIZED AGENT ❑ <br /> ! If APPLICANT IS not the BILLING PARTY Proof Of auth0rizati0n 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it Is provided to me or <br /> my representative. P r <br /> TYPE OF SERVICE REQUESTED: Q RECEIV Z <br /> COMMENTS: l —7 pPR,2 1 ace 1:7-7� x� SAM JOAQUIN4 2 16 <br /> C UN <br /> HEq TVIROMENT L TY <br /> H DEPART ENT <br /> I <br /> ACCEPTED BY; EMPLOYEE#: DATE: !11 - <br /> ASSIGNED TO: U00 <br /> 0 CA EMPLOYEE#: DATE: <br /> Date Service Completed (if ady completed): SERVICE CODE; PIE: 1• O <br /> Fee Amount: `��`� Amount Pati /30. v,,�) Payment Date <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />