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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/OPERATOR <br /> 1,-r5 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS. I% J IJ T/� C <br /> �� Street Number Direction t/ �etreet Name ` Ci dde <br /> HOME 0 MAILING ADDRESS (If Different <br /> `fromm Site Address) <br /> Z1 7 f J R I 1! " z � Street Number Street Name <br /> CITY `4C A STATE ZIP 76 <br /> PHONE#11 EXT. APN# �{ LAND USE APPLICATION# <br /> ( 20�? - 7 &-1-077 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /•� /M(�� �L �r--I• CHECK if BILLING ADDRESS O <br /> BUSINESS NAME �7 / ,�[ PHONE# EXT. <br /> HOME or MAILING ADDRESS I r FAX# <br /> CITY 211 C STATE( ZIP Z <br /> BILLING ACKNO LEDGEMENT: 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 FEDERAL laws. l <br /> APPLICANT'S SIGNATURE. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ' �y <br /> COMMENTS: <br /> �iqy Fi`� r <br /> till�,o N�Ncolp�9 <br /> FA FNT�N <br /> ACCEPTED BY: arm S EMPLOYEE#: DAAFF1711q <br /> ASSIGNED TO: EMPLOYEE#: / DATE: CJ I <br /> Date Service Completed (if already completed): SERVICE CODE: / P 1 E: / <br /> Fee Amount , Amount Paid `,5D Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />