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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/OPE TOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 1 19 Al <br /> SITE ADDRESS DF <br /> ( 2� <br /> / Street Number Drl —v. Kt J-`O Street Name �� CI ZI C <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY --I STATE ZIP <br /> PHONE#f E APN# C LAND USE APPLICATION <br /> cia (IPHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME (' PHONE# Exr. <br /> HOME or MAILING ADDRESS FAx# <br /> O G L ) <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 /> I also certify that 1 have prepared this applica'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,SrarE FEDERAL laws. <br /> O<APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNERPERAT R/MANAGER ❑ OT R AUTHORIZED AGENT <br /> th ❑ <br /> If APPLICANT Is not LING PARTY proof of authod tion to sign is 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/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it Is available and at the Same time It Is provided t0 me Or <br /> my representative. l n <br /> TYPE OF SERVICE REQUESTED: � 01(, 5ct.�/ #y�tllp-\ /fp�y,y� lam'y` <br /> COMMENTS: YL�iIkS� VT1Jt��•- �� f DSS18L'L cS✓ iss>�s t)1Y= DSS � / <br /> 1-0�rr s�� Nr,✓>�-s✓r, N►a�ntN1 �, „ OCT 2 0 ton <br /> n - 1 $JW VFIRONNCOUNTY <br /> (/ �/ ENVIRONMENTAL <br /> ENT <br /> ACCEPTED BY: �0.�o I EMPLOYEE - <br /> ASSIGNED TO: EMPLOYEE#: DATE: lo- IG_l (, <br /> Date Service Completed (if already completed): SERVICE CODE: Z PI E: (,U 1 <br /> Fee Amount: 1 1 �� Amount Paid 3 v Payment Date <br /> Payment Type G _ Invoice# Check# 6 C1 - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />