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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> -54;wan+ 1-17- <br /> OWNER/OPERATOR <br /> PvtIWMI CHECK if BILLING ADDRESS� <br /> FACILITY NAME <br /> � a1.�Vt�WfaeT <br /> SITE ADDRESS N S <br /> DStreet Number Direction SVee[ me � <br /> Zip Code <br /> HOME Or MAILNGADDRE m Address) <br /> I <br /> Street Number J�S.v'✓��Streeme <br /> CIN 4a--Jopl STATE Zip ZIP <br /> 1. q5?--fT- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 6b <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A^ <br /> J�`� Vt �I'Vl�� CHECK If BILLING ADDRESS <br /> BUSINESS NAME `tom rY� PHONE# EXT. <br /> a IJ�T' Iwti (4(11) <br /> HOME or MAILING ADDRESS FAX It <br /> 7A ( ) <br /> CIN � I 1_� STATE C <br /> ZIP <br /> GK�To <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 application and that a work to be performed will be done in accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA E and FEDERAL s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assessDppp1le�-�nt information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is 'Iysd�d t0 me Or <br /> my representative. t rr <br /> TYPE OF SERVICE REQUESTED: 4cich o1-) <br /> COMMENTS: I <br /> ✓O <br /> 8 <br /> ,,qZ?Q?q�p r' <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE - DATE: <br /> Date Service Comple (If already completed): SERVICE CODE: C I P/E: I oZ <br /> Fee Amount: I Amount Pa' Payment Date 14-11 <br /> Payment Type Invoice# Check# /Di( Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />