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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IMPARTMENT � <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES <br /> aan(ikw T,4 01-15V& <br /> OWNER/00E TOR <br /> f [AVO—k/ <br /> 1$ / CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 '�/ <br /> SITE ADDRESS /I //nnff�� '6h uywt/�� .�Qf C/��/'y7' <br /> 9Siree14 er /rection Bt et Name (JCI / v�/��.�JQ <br /> Z1 Lode <br /> HOME Or MAILING ADDRESS Of Different from it Address <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) -a97a <br /> VOE _ / &o <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ICHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE ///n� ET• <br /> Al I <br /> HOME Or MAILING ADDKIESS C FAX# O 1 <br /> fq(l ) <br /> CIN STATE ZIP <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standarr <br /> TATE and FEDE L laws. � o/D� <br /> APPLICANT'S SIGNATURE: a h h I DATE: J� / A <br /> / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Imo/ <br /> If APPLICANT is not the BLLLING 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 <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: Sme>c f PAYMENT <br /> COMMENTS <br /> NOV 6 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> DEPARTMENT <br /> ACCEPTED BY: C)4- VC=-1 EMPLOYEE#: ®�u DATE: Oh' <br /> ASSIGNED TO: O ` r--A-P I�-- EMPLOYEE#: Z t f Z y DATE: 111410?- <br /> Date Service Completed (if already completed): SERVICECODE: �qv IPIE: �O <br /> Fee Amount: 4 '3t S cmD I Amount Paid y¢ 3 ( S, D0 1 Payment Date (I <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 '..SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />