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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property TFACILITY ID# SFRVICE"tECLUEST# <br /> OWNER 1 OPERATOR <br /> 541 f f CHECK IfESILL1NGAt)DRESS� " <br /> FAclLITY NAME l� [— <br /> SITE ADDRESS <br /> Street Number Direction Street Nami Code <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> CV @;41><- �� 2fy StreetNl <br /> CITY <br /> PHONE#t EXT. APN# <br /> 11� �/�t`-tet�" C ► �'`�s f') Li `' <br /> } <br /> PHONE#2 Exr. <br /> CONTRACTOR/ SERA <br /> R£QUESTOR <br /> f0 � ESS <br /> BUSINESS NAME <br /> COS,) C-� A- r N zz <br /> HOME:or MAILING ADDRESS f <br /> �O l <br /> CITY n „ �O 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 or <br /> activity will be billed to me or my business as identified on this farm. <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 laws. <br /> h APPLICANT'S SIGNATURE: DATE: Sf(2r!9 <br /> i <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑. OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLINGP.IRT proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: s o f c_. S u c 77}�S C—r � PAYMENT <br /> COMMENTS: RECEIVED <br /> MAY 12 2008 <br /> F SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> JJEALTH DEPARTMENT <br /> ACCEPTED BY: ©L 1 U� EMPLOYEE#: p 32 f DATE: S r O <br /> ASSIGNED TO: EMPLOYEE : �3� DATE: J 2 p g <br /> Date Service Completed (if already completed): SERVICE CODE: $ Zv P 1 E: 4'd <br /> Fee Amount: Amount Paid 4 L / b _ O D Payment Date �T( <br /> Payment Type invoice# Check# (off. Received By: �. <br /> EHD 48-02-025 Sf FORM,(Golden Egad), <br /> REVISED 11/1712003 <br /> k _ <br />