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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 /> ( � .� CHECK If BILLING ADDRESS <br /> LDEEP- <br /> FACILITY NAME (/ <br /> SITE ADDRESS 1031 <br /> 57 <br /> _n���1 ?Kff7 <br /> Street Number Direction /Y/� treet NamVe City L' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> r Street Number (� vStreet Na/me <br /> CITY STATE ZIP X <br /> J � <br /> PHONE#1 EXT. APN it L LAND USE APPLICATION# <br /> Jim <br /> PHONE#2 ` EXT. BOS DISTRICT i F <br /> CATION ODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> f L— LTJ : 7 CHECK If BILLING ADDRESS, <br /> BUSINESS NAME ' PHONE# Ex,. <br /> HOME or MAILING ADDRESSWFAX# <br /> ILF /a ( ) <br /> CITY n 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:1QY—IV-19 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Till e <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 /> to 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: F P, P <br /> COMMENTS: <br /> ocrSAN JO 1® <br /> H �Rp U/NCO 018 <br /> FAQ N UN <br /> ACCEPTED BY: e�� (CA <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: C Q r�� - EMPLOYEE#: DATE: `Q. / O <br /> Date Service Completed If already comple d): SERVICE CODE: G— -2 P1 E: O <br /> Fee Amount: C d() Amount P �� 0 Payment Dattel d�Q <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> -v5 °,7- <br />