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SAN JOAQt,..a COUNTY ENVIRONMENTAL HEALTH L..,�PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UEST# <br /> (7 C J <br /> OWNER/OPERATOR n n <br /> "-�v r�iI� CHECK If BILLING ADDRESS <br /> FACILITY NAME 4 J� 1 �/ � IIIJJJ��� <br /> SITE ADDRESSEAI TE' �O f C /"I TE_ J !`'� 1Z4r-1^ <br /> `/.1 PI' 'I Street Number Direction Street Name City ZI Code <br /> HOME Or MAILING ADDRESS (If Different from to Address) <br /> /Off1O `/'14 r-/"I <br /> / U Street Number Street Name <br /> CITY �^/4/Tg C ^ STArZI <br /> � <br /> PHONE#/''� /� ExT. APN# / LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT / LOCA I N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR_ <br /> Y/1yt-/I ,,,/i 9r, le ( L�6;�\ + CHECK If BILLING ADDRESS <br /> BUSINESS NAME t/,7 \' �J. / PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> Gid N'G,U"n t:vv+y I ( ) <br /> CITYiMo H,Tk cl J �� STATE �_ ZIP Of 3q /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 FEDERA7'�' <br /> APPLICANT'S SIGNATURE: �'cz��a,,�?,P i➢ 4" DATE: <br /> PROPERTY/BUSINESS OWNER O 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is pA Ame or <br /> my representative. �6 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: p <br /> 1 201? <br /> e-.r , SAM <br /> C9' GI vl dOAQU <br /> NFgEIN C� <br /> "CTHDAA <br /> Nr <br /> ACCEPTED BY: a EMPLOYEE#: DATE: I' � - I <br /> ASSIGNED TO: I EMPLOYEE#: DATE: l /. /-7 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: I <br /> Fee Amount: I CJ Amount Paid` U D Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />