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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 ` t <br /> 1-rlyDE 12 /1 T'r1V'fA11 9 CHECK If BILLING ADDRESS <br /> FACILITY NAME ✓JN�ff <br /> SITE ADDRESS <br /> 7/3 S' sP�G��i G ,�I✓6 �(aC-- zz cl y S 2 0 > <br /> Street Number Direction Street Name city Zin Code <br /> HOME or MAILING{'ADDRESS (If Different from Site Address) <br /> !— C <br /> Z 3 J V fy�✓ ��K �L- Street Number Ja�C� N� Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> 7 7 c e <br /> —7 PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Al <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> Iso s. 9j 6-S— (5'iv) 3)-Z- <br /> CITY 21�l�N K STATE C 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: 5� 1 DATE: 3/l, / <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 asse//��++gg eynt Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS - Yll��jV�r <br /> my representative. R a <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �J tae /y SAN JOq 019 <br /> L` "_��I ENVIRONI N COU <br /> HEALTH pEPARTTAL N <br /> ar-f=15gna i n� L' J Y 4aA' (-0 Y✓7 MENT <br /> ACCEPTED BY: �rl"L uC-Q EMPLOYEE#: DATE: �1 r <br /> ASSIGNED TO: l� 0kVC-C- EMPLOYEE#: DATE: ✓� 1 —�\GS <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: / O/ <br /> Fee Amount: Amount Pai Payment Date <br /> Payment Type Invoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />