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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9 1- zEs15t?,0077 3) <br /> OWN�ER�I OPERATOR <br /> I-/R. ESE a1EL AI— A CHECK If BILLING ADDRESS <br /> MR. <br /> FACILITY NAME <br /> SITEADDRESS ��T/7� In/ CLO✓EP2 R-0 , TRAcy/ 9530' <br /> Street Number Directi.n Street Name Crr Zi Code <br /> HOME Or MAILIN5 G ADDRESS,51�1f Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> 0o ) 346 - a a -0Z co - N/A <br /> PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> ( ) 005 �► <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DONV r /� r C e CHECK If BILLING ADDRESS <br /> BUSINESS NAME r C� IN PH d NE# — Ex,. <br /> (403 <br /> HOME Or MAILING AORESS ��� FAx# <br /> -ZS <br /> CITY STATE C 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 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,ST ' and FEDER4,eVIS. <br /> APPLICANT'S SIGNATURE: PATE; 7- /7 - ( 7 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ THER AUTHORIZED AGENT X <br /> If APPLICANT Is not the BILLING PARTY,Proof Of auth ization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the pwner 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 as mp�e�nt��in�formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time I IBN�.�me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I/1 Tktl rE "A: �;Tu p EV,�!�f E D <br /> COMME TS: ?O}� <br /> / SAN e/vI <br /> iQ(�ny✓� HEACAQUI/V CO <br /> THOF A1ENTgN� <br /> �'�JCI'F� �TMENT <br /> ACCEPTED BY: �w,t' 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: T � v EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: a(,O <br /> Fee Amount: ICJ Amount P 3d , 0 D Payment Date <br /> Payment Type /7 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />