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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> rywp:ef Business or Property FACILITY ID# F' 3 SERVICE REQUEST# <br /> `��G1 iUJL� CAL,q;] (rOC��3-70 <br /> NER l OPERATOR U ( CHECK If BILLING ADDRESS <br /> 'f �•'�'S '1—G <br /> FAcILrrY NAME 4�r / r '-�e 1;72- <br /> SITE ADDRESSty p '+ r � S to��F+ f za.�J c�°�►• �t'S�� 7 <br /> Street Number Direction Street Name Cif Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /3 Z ('• w Street Number E Street Name <br /> CITY STATE ZIP <br /> PHONE#11 AP N# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT { LOCATION <br /> CONTRACTOR/ SERVICE REQUEST©R <br /> REQUESTOR CHECK ifBILLING ADDRESS, <br /> PHONE# Exr. <br /> BUSINESS NAME C�. -� `` ((lo I yao—07'i// <br /> �.3�" rt. ar✓ Il rL.� <br /> HOME or MAILING ADDRESSFAX# <br /> 173 ± 5 c (4.08 ) 11690- 0,511 <br /> CITYS✓ ob' STATE ZIP <br /> BILLING AC OWLEDGENIENT: 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: - ` "- DATE: <br /> PROPERTY/BUSINESS OWNERO O TORI MANAGER ❑ OTHER AUTIrORIZED AGENT/K rp 4 L <br /> IfAPPLIGANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORi`vIATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: b V <br /> i - <br /> COMMENTS: REOEIVD <br /> rF. Ire` <br /> AUG 1 2006 <br /> SAN JOAQUIN COUT!TY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: 7DATE. <br /> ASSIGNED TO: EMPLOYEE#: �J <br /> Date Service Completed (if already Completed SERVICE CODE: P! � <br /> Fee Amount: U9 �(�iZ• Amount Paid Payment Date <br /> Payment Type invoice Check# Received By: i <br /> �. <br /> SR FORM(Golden Rod) <br /> EHD 48-02-0725 <br /> REVISED 11/17/2003 <br />