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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =,_SERVICEUEST# <br /> CoMk� :'1� 025 5 �i�bcL �zcN . 3e� <br /> OWNER/OPERATOR <br /> JFA4JI <br /> At AA 'tl/ CHECK If BILLING ADDRESS <br /> FACILITY NAME K <br /> SITE ADDRESS (fl P1 <br /> 2/O3 Street Number Direction /L / eK,ll I i Catle <br /> HOME or MAILING ADDRESS (If Different from S-Site Address) pr <br /> POr box et b StreNumber Street Name <br /> CITY STATE ZIP �yS LrJ� <br /> Cit S y <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (Z04) -7L+ti — 2586 PA - i / 000 l <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAx# <br /> l 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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 IawS. <br /> APPLICANT'S SIGNATURE: 4e-- DATE: 0p <br /> PROPERTY/BUsrNESS OWN ER)� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ffAPPL/CANT is not the BILLING PAR TT proof of authorization to sign is required Title <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: netj - <br /> COMMENTS: / RECEIVED <br /> N /l <(p0/Kin ) l4dGc�L�vc nzasvt -...cs <br /> d�AUG 30 2011 <br /> JOAQU/$/I/ /Otylr✓1 J Ij✓f.Gd tLLG (N,t ta.ctyf•Yt2r,f- �J![�u- ✓`e v.zl.— w/ /.�I� . <br /> Io JN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: _- EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: VV <br /> Date Service Com leted (if already completed): SERVICE CODE: �� PIE.. O <br /> Fee Amount: Amount Paid �5O Payment Date J <br /> Payment Type ✓ Invoice# Check# Q R ceived y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />