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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11-711\ 000 .Z� 111 <br /> OWNER/OPERATOR N`I CAR ,-C OS CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME jey-tvq <br /> SITE ADDRESS U SkD K�C��O���+ ►'v` �ZUZ <br /> Street Number Direction Street Name City ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address)/ <br /> CStreet Number `'Strame <br /> CITY �_'L1��_ \ $TATE, ZIP <br /> PHONE#1 J EXT. APN# LAND USE APPLICATION# <br /> (201 CA 2,Z- `&J1$ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> �BUSINEss <br /> ►/L t7S NAME y.��'t IS I_ t✓n PIlQN /;��— go l EXT. <br /> HOME or MAILING ADDRESS__;2 (AX# ) <br /> CITY ����`� STAT'j ZIP okG�,2 <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 FEDERA <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANTs of 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 /> 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 /> PAYME <br /> TYPE OF SERVICE REQUESTED: }�� �� REGE-WED <br /> COMMENTS: \�(tr`r�� <br /> 1` OCT 2 3 20 <br /> SAN JOAQUIN CO NTY <br /> ENVIRONMEN AL <br /> HEALTH DEPART ENT <br /> ACCEPTED BY: 11EMPLOYEE#: DATE: V Z�,-� <br /> ASSIGNED TO: EMPLOYEE#: DATE: Ivo—Z I <br /> Date Service Completed if already completed): SERVICE CODE: �� I PIE: j�L' 2 <br /> Fee Amount: 0-``7Z C Amount Paid rZ S Z Payment Date Cf] a 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />