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SAN JOAQUIY 17OUNTY ENVIRONMENTAL HEALT- 7EPARTMENT <br /> SERVICE REQUEST 1�w <br /> Type of Business or Property <br /> 7!n7l= <br /> ---F <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> .25. <br /> FACILITY NAME <br /> F,5eclCN <br /> SITE ADDRESS �BS�/� q bl/�/E R�AQ JrTGCKTaA� 9�2t S <br /> Street Number 1 Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ems' APN# LAND USEAP LICATION,F <br /> /V ////// oV <br /> PHONE#2 ExT. DOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 7�O CHECK If BILLING ADDRESS er <br /> AJ <br /> BUSINESS NAME 1l/1 G PHONE# E '. <br /> C 4E 5nl SG! T <br /> HOME or MAILING ADDRESS FAx# / <br /> 6oJ� 7 " <br /> ( ) O-z S%S <br /> CITY STATE CA <br /> ZIP �3 / <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 appli 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E nd FEDE <br /> APPLICANT'S SIGNATURE: DATE: 12 -3o -08 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER ❑ OTHE AUTnORIZED AGENT <br /> �f APPLICANT is not the BILLING PARTY proof of anthoriz ion to sign is required Titte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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: SO/L SGf/7A 6/L /T S�uD �/ Ei1/ PAYMENT <br /> COMMENTS: <br /> DEC 3 0 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 32 I DATE: 12_ 30 27e <br /> ASSIGNEDTO: .SI- -POL-CG.-O-� EMPLOYEE#: If-6 ttZ' DATE: �L 3a 0 �' <br /> Date Service Completed (if already completed): SERVICE CODE:5-OZ P/E: O <br /> Fee Amou 4 21O,t VI I Amount Paid at p , O� Payment Date N-)-130(c <br /> Payment Type L j" Invoice# Check# a.�j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />