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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U Gov -"X . c7D2-W�"•D- COO CJ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L j6 1 Cil U b <br /> SITE ADDRESScs��� N 2 G\Z)C K (ON <br /> Street Number Direction Street Name city Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I C�) '— -\) Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 2-CjC, <br /> --7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> r CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> k-, <br /> BUSINESS NAMEPHONE# EXT. <br /> _ <br /> HOME or MAILING ADDRESSs� •m ' <br /> (,CITY �v ZIP C7-:Il 1 V� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned propertybusiness owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specificVIRONME AL,'IE TH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as ide ified on t s f <br /> also certify that I have prepared this applie n�ar�d tai ork to be performed will be done in acY71bll SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards nd� DE L IAPPLICANT'S SIGNATURE: DATE: / 1 <br /> PROPERTY I BUSINESS OWNER❑ =ATION: <br /> N R ❑ OTHER AUTHORIZED AGEN <br /> If APPLICANT is no proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INWhen 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 pito me or <br /> my representative. '�►/�I� <br /> TYPE OF SERVICE REQUESTED: �C C, l !� 4V <br /> COMMENTS: SQN J0AQE �015 <br /> EIVqTq�NNC4'"O � <br /> TMFNT <br /> ACCEPTED BY: � EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: I ' <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: -;bC1000 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />