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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UEST# <br /> O 'Z��4� �2 �0-) 7,01 �012 <br /> OWNER/OPERATOR _ \ <br /> Q � ©S� A, O r 'C—O CHECK If BILLING ADDRESS <br /> FACILITY NAME OJ`�/ k Q c- V Q-- u �f✓` S t L) Ax <br /> S TE ADDRESS <br /> 7 Street Number I Direction tdNa e C) Zi Cod/e <br /> 'TME Or MAILICNG ADDRE1SS` (If Different from Site Address) <br /> agD Y !v 0 1�-Cq- Street Number Street Name <br /> CITY �.� $T TE ZIP 7 5 33U <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# U <br /> PHONE#2 - <br /> 55EXT. BOS DISTRICT LOCATION CODE <br /> (� 9-5 5 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> Ws J�, U C- <��.l U CG CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` C PHONE# EXT. <br /> k �9 <br /> � <br /> HOME or MAILING ADDRESS FAX# <br /> (L-AJ <br /> CITY / ( I STATE C ZIP (7-53-3z) <br /> BILLINrG—ACKNOYWLEDGEMENT: 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 FEDER aws.--� <br /> APPLICANT'S SIGNATURE: `` DATE:_ C?�! — - C� <br /> PROPERTY/BUSINESS OWNER❑ OPE ATOR " AGER, OTHER AUTHORIZED AGENT El APPLICANT is not the BILLING PARTY,proof of thorization 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 to me or <br /> my representative. 4 <br /> TYPE OF SERVICE REQUESTED: CE <br /> COMMENTS: F`Q 06 6 20l <br /> JOq <br /> �� RONMF OLIN <br /> N OEPgR MSN <br /> ACCEPTED BY: t� _Q> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <� I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /^ P I E: O <br /> Fee Amount: 2-Q Amount Pa 5,2,OD Payment Date / <br /> Payment Type ( K Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />