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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> O CHECK If BILLING ADDRESS <br /> K W WarU <br /> FACILITY NAME <br /> A Q,JVvw <br /> SITE ADDRESS Street Number Directi Street Name city ZID Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /�}�S 2 S <br /> l `rS'treet Number Street Name <br /> CITY STATE ZIP l <br /> S <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (2'9 ) 33 1 -0 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 3 �1 05- <br /> HOME or MAILING ADDRESi FAX# <br /> 1 (2-05) 338 3 <br /> CITY Lo at , STATE el-q- zip S zq <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: ' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIVNAGFR Va OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BimNG PARTY,proof of authorization to sign is required Thie <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: LC S T J <br /> C_0 S LC 0 RECEIVED <br /> COMMENTS: e5:, /lfr 56q/�(��,L��T <br /> ✓`aZ�' ` ��LL / v C�! FEB � 2008 <br /> '• !� �/� "6U — ` S� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2i DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: AD P/E: 3 <br /> Fee Amount: 1 '�-' �'"D Amount Paid (� &TC) Payment Date Fjb7 <br /> Payment Type ��� Invoice# Check# Received By: % <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />