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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST"# <br /> 00�of <br /> OWNER/OPERATOR <br /> AF45 WI�fQMS CHECK If BILLING ADDRESSC� <br /> FACILITY NAME <br /> SITE ADDRESS 3 1=024 ZIB'f— X&A-O LIu06u gsZ'Xo <br /> 8 reetdVumber7 <br /> Di action Street Name Ci 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2 7f PANAPA*t A D& <br /> Street Number Street Name <br /> CITYl � fid &CNT� STATE44 ZIP �IZ,� <br /> FHONEL#1✓r `�C E"Y- APN# LAND USE APPLICATION R <br /> -71 <br /> PHONE#2 EXT. BOS DISTRICT LOCATIOy�O E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> i <br /> REQUESTOR ( ISG -(—bl ISG-(-bCHECK if BILLING ADORI=55® <br /> BUSINESS NAME PHRNE# EXT. <br /> N1v+�PK� 33�-6613 v <br /> ROME or MAILING ADDRESS FAX# <br /> �•o. Stix ZfSo (241 ) 574- 07Z3 <br /> STATE ZIP is <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 1 have prepared this application and that the work to be perfo till be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE ED laws. l <br /> APPLICANT'S SIGNATURE: DATE: Z �� <br /> PROPERTY_/BUSINESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sigh is required Title <br /> able I the owner or operator of the roe located fat the: <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, p property rty <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 JOAQU[N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time'it is <br /> provided to me or my representative, 11 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ft,(� PAYMENT_:, <br /> RECEIVED <br /> l <br /> DEC .-9:-2010. . <br /> O �� ��f t } SAN <br /> ENVVIIRONIMENTAL <br /> WE AJ-TW DERAQTUP <br /> ACCEPTED BY: O LJ E t EMPLOYEE#: 03.3 / DATE: <br /> ASSIGNED TO: T—S C-0m EMPLOYEE#: �� DATE: <br /> E <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P!E: Z(p© <br /> 2 <br /> Fee Amount: Amount Paid a 1` Payment Date <br /> Payment Type `� Invoice# Check# c> 2'A O Received By: qv,& <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />