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SAN JOAULJIN COUNTY ENVIRONMENTAL HEALIREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �o �t�-t �'A l����' 5/zx7(3667 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS Er <br /> FACILITY NAME <br /> SITE ADD�REESS <br /> 6.X0 SUeet Number I imon - Slreet Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from�S�ittqe Address) <br /> Vso 1.x.7 C Ct VT0)- uon Street Number Street Name <br /> CITY DC K 10 <br /> A STATE ZIP /� � b 6 <br /> PHONE#1T' APN# LAND USE APPLICATION# Y <br /> c5to S6S- 6cro <br /> PHONE#2 ExT. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REDUESTOR <br /> \jam' CHECK It BILLING ADDRESS� <br /> BUSINESS NAME55o / I- (_ \ PHONE# EXT. <br /> HOME or MAILING ADDRESS Cif�A.�T(f! V�J FAX# <br /> n 6N- G(SZp I ) <br /> CITY STATE ZIP <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 /> also certify that I have prepared this applicatio an that q.W/ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a d FE ER aw / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER WJ OPERAOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof of authorization to sign i5 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/siteQQQQ sment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same tlfrL Kl6 J.� Me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: N K-z''v l (� <br /> COMMENTS: �OrO <br /> SAN Jqy <br /> !i FNVIRpNINCOUN <br /> EALTNOE N]y <br /> ACCEPTED BY: / +/J,[+/�` EMPLOYEE#: DATE:I—/G �l <br /> ASSIGNED TO: - r t^ EMPLOYEE DATE( ^(O i/ <br /> R <br /> Date Service Completed f already completed): SEVICE CODE: J�� 1 PIE: l <br /> Fee Amount: -A(.S Amount Paid o U Payment Date I <br /> Payment Type Ca, Invoice# Check# Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />