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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> tFACIUTYNAME <br /> s or Property FACILITY ID# SERVICE REQUEST# <br /> Z-ra -5,200 �IBzS <br /> ATOR <br /> L TE2 CHECK If BILLING ADDRESS My <br /> egO 2 S F,4 A17A 7—eACy 95-30 / <br /> Street Number Direction Street Name City Zm Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1061 G? 7_,r/ <br /> Street Number Street Name <br /> CITY L m r T STATE 0 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# /'^ U <br /> lzl <br /> PHONE#2 EXT. BOS DISTRICT LOCATIONCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> N ClA576A(EPC CHECK if BILLING ADDRESS E] <br /> BUSINESS NAM- PHONE# EXT. <br /> ES Con/Su o-'2-- 6s <br /> HOME or MAILING ADDRESS FAX# <br /> K 3 7 (moo (vd 8-Zsq <br /> CITY I— nv STATE ^n zip S3 / <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAand FED L WS. <br /> APPLICANT'S SIGNATURE: PATE; 3 /S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of aut orization 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 as It IS available and at the Same time It Is provided t0 me or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: f411, Su/-rr3/L/T f TuD RF V1 F v,/ fC2 <br /> T <br /> COMMENTS: AR, D <br /> '� � SAE dog_ 6 20 <br /> Th pF q�TAI Ty <br /> ACCEPTED BY: 1 - EMPLOYEE#: DATE: J(Z s <br /> ASSIGNED TO: EMPLOYEE#: DATE: 7 l <br /> Date Service Completed (if already completed): SERVICE CODE: y )_ I P/E: 2 6 iu <br /> Fee Amount: ,. 2 6l7 �, Amount Payment Date .3� <br /> Payment Type Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />