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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPE R f <br /> /t yl Crrr cn N [Tu } iN( ; Aunut_ Ss � <br /> FACILITY NAM (M --- - - - - - -- - - - _ _ _ -. <br /> UI � <br /> SIT ADD ES 45 '��µ• A. ,� / �„ (/l��l /�I � 19q2 StrootNumber Strouutt ' mno � ��' ` - ' � <br /> HOME or Ar ADDRES f Different from Site Address) <br /> t _ __ _Slront umbar Strool Non c� <br /> CITY 5 �`� TE s& ! / <br /> P , 7 1 � p Ext APN # LAND USE APPLICATION # <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUES'I'OR <br /> REQUESTO �( PwxmxtCHECK If BILLING ADORES <br /> BUSINESS NAME r 1 �� 56, E v// � n PHONE # Ext • <br /> HOMED I RESS 1 [P ydq •C FAx 0 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all sit0 and/or projoct specific ENVIRONMENTAL- HCALTH DEPARTMENT hourly chargou associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this appligaliDtl that the work to be performed will be done In accordance with .III SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S An EDFRAL laws. ` (` <br /> APPLICANT' S SIGNATURE : it —�P �fn r �' rJS vrl DATE : <br /> PROPERTY IBUSINESSOWNER ❑ OPERATOR I MANAGER OTHER AUTHORIZED AGENT ❑ t� 1011r1M (ll' � i) C <br /> If Appi (CANT /s not 1`11013ILLING PAIr )Y, pro; f 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 ENVIRONMPNTAI HrAt Ti I DrPARTMFNT as soon as It Is available and at the some time It is provided 10 me or <br /> my representative . <br /> TYPE or, SERVICE REQUESTED : -- � � Q C� A <br /> or <br /> COMMENTS: FN <br /> S� U -t k� oo`t ri a% A <br /> SAN FN �FFABQ�0/ c <br /> 24 <br /> 20 <br /> O <br /> ACCEPTED BY N <br /> I DEN��/ / Z A <br /> ASSIGNED TO: /yffn /r t EMPLOYEE #: DATE: � <br /> + TMENr <br /> a a 24 <br /> Date Service Com eted (H already completoW. SERVICE CODE: 0 � 2Gl PIE: 0 <br /> Fee Amount: � 2 Do Amount Pai lea, Or,) Payment Date a-/742 <br /> Payment Type invoice # Check # I I d Recei ed By: <br /> CHO 48-02-026 SR rORM (Golden Rod) <br /> 07/ 17/08 <br />