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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER It OPERATOR <br /> •�� ����+_�y�`% CHECK If BILLING ADDRESS <br /> FACILITY NAME MAW T <br /> SITE ADDRESS F 4 vE ST0C�JN 7 0, <br /> Street Number birection A Name CI " ZI Code <br /> floc.E Or MAILING ADDRESS (If Different from Site Address) //Dc) 80 CT <br /> treet umber I Street Name <br /> C'7 Y 13 CMIN STATE ZIP <br /> f^ U <br /> PHONC#. EXT. APN# LAND USE APPLICATION# <br /> &/ 207, <br /> R IONS#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REGUESTOR <br /> CHECK If BILLING ADnRESS ... <br /> BUSINESS NAMcP ,I . I� ��� / —�/ PH NE - 9077 EXT. <br /> HOME Or MAILING ADDRESS r/ Y 00 ;tw /N FAX# <br /> CITY �ay� �/� r` ' — — — STATE (>I ZIP 1C <br /> BILLING ACKNOWLEDGEMENT: I, the .Indersigned propart,, :us;r owiler, cperatar or authorl.eJ agent of same, <br /> acknowledge that all site and/or project specific ENVII,ONMEN r,,L HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will bE b 'ed to me or my business as identifieL' this form. <br /> �:.so col 'y tha' `ave .repared this licat n an 'gat the work to be performed will be do �e in at-Cordal :e with all SAN JOAQUIN <br /> CCJNTY C -dii Icr ;,odes, Standards, TATE F= -RAL laws. <br /> APP!ICANT'S SIGNATURE: DATE: 0/- <br /> PROPERTY/ <br /> /_PROPERTY/BUSINESS OWNER 5( OP R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorizatir n to sign is required Title <br /> AUTHORIZA'i ON TO RELEASE INFORMATION: W!,e!l applicablE;, 1, tha owier or operator of the property located at the above <br /> site address. hereby authorize the release of any and all results, geotechnical d.ita and/or environmental/site assessment information <br /> to the SAN JOAQI IN COUNTY ENVIRONMENTAL HEALTH DEPAP'TMENT 2S soon a it is ailable and at the same time It,.> me or <br /> my representatives F ^ <br /> TNPE OF SERV.;E REQUESTED: �0 (� ale I/e6 <br /> COMMENTS: SA2016 <br /> EJOA QUIN <br /> NEAcrH oo q , <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ <br /> ASSIGNED TO: N 1 i EMPLOYEE#: — DATE: <br /> Date Service Complete (If already Completed: SERVICE CODE: - 4 j PIE: w <br /> Fee Amount: p� Amount Pad 3 G d Q Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />