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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o Y,a 105� 501") <br /> OZINER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SFE,A^^DORE55 �Q,� L,-�+� q <br /> tJ� Street Number Direction O Ma11�1 Stre�itYme C�' "� ``z�i �deZ <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> CITY Street Number Street Name <br /> STATE Zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2T <br /> z�1BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \��' C ^ <br /> vciI,�^ , J 1 � \ CHECK KBILLING ADDRESS <br /> BUSINESS NAME. Exr. <br /> o�A 2 PHONE# /p S _3 <br /> s 19 <br /> HOME or MAILINDD ESS FAx# <br /> a0iA <br /> O YV\'9V\ (24ef I — 2001 . <br /> CITY STATE 01 <br /> Zip d(S 2-1 Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> knowledge that <br /> acall 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 El OPERATOR I MANA ER OTHER AUTHORIZED AG ENT ❑ <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required rtrte <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It 19+Djgyl_ded to me or <br /> my representative. I�/9�/� <br /> TYPE OF SERVICE REQUESTED: L�'e e <br /> COMMENTS: OCT25 <br /> ` Y <br /> ?5101) <br /> ISMJOAQUlifAlTy p11.P��gtfY, <br /> ACCEPTED BY: p EMPLOYEE#: DATE: <br /> ASSIGNED TO: O 1 EMPLOYEE#: DATE; <br /> Date Service Completed ( Ireadycompleted): SERVICE CODE: PIE: <br /> Fee Amount: 5 2 — Amount Pa' /5� Ub Payment Date �� <br /> Payment Type �y Invoice# Check# L..� Received y: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />