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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQi1EST# <br /> F/A100)DW (��� 5- ql <br /> OtalniER 1 OPERATOR FP+ <br /> M V Nim S CHECK If BILLING ADDRE551:1 <br /> FACILITY NAME <br /> SITE ADDRESS -77-J-)-3 <br /> DDDRIESS93 <br /> �CY _ � n � �— yyy <br /> C Street Number Direction �� _ G 1� � <br /> D lJ Srrapt _mn 7iri �7 <br /> HOME Or MAILING ADDRESSIf Different from Site Address) <br /> _ 1 D S,q,� �,T� Cz, <br /> Street Number Street Name <br /> CITY <br /> S;PTE zip <br /> C� 3 <br /> PHONE#f EXT. APN# LAND USE APPLICATION# <br /> (951) 302 - LIZI <br /> PHONE#2 Ezr. SOS DISTRICT LOCATION CODE <br /> 1 } <br /> CONTRACTOR SER1710E REQUESTOR <br /> REQUESTOR <br /> PIP,) 1>0 S CHECK If BILLING ApDRESS <br /> BUSINESS NAME PHONE# Exr, <br /> lav r-) -A L 5 7 = 44 7 `Z-- <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <br /> J <br /> BILLING ACKt EWifLEDGEhriENT: 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 /> 1 also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUiN <br /> COUNTY Ordinance Codes, Standard and FEZ laws. <br /> APPLICANT'S SIGNATURE: .. /) DATE: <br /> PROPERTY I BUSINESS OWNER P 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, 1, 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, i <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: h1 <br /> G1no►n l c o w o er- SAIoEP 06 2116 <br /> aQU11V <br /> yEA11,4100aEN <br /> Ir NTM <br /> N!` <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: _ _ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: v� <br /> t <br /> Fee Amount: ` Amount Pald05 13 �Zj Payment Date <br /> Payment Typei Invoice# CI;eEk# { 7 Received By: <br /> EHD 48-02-025 5R FORM(Golden Rod) <br /> 07/17/08 <br />