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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property T FACILITY ID 0 SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK It BILLING ADDRESS <br /> �(�/�L�/�ACSsae'/O <br /> FACLM NAME <br /> SITE ADDRESS e�3�OD Zr- r'l�� G/ ei'1 9sa3l� <br /> Stnet NumEer Direction Street Nams Ci ZI Cade <br /> NOBS or MAILING ADDRESS (If Different from Site Address) <br /> Stnet Number Street Name <br /> `.m STATE ZIP <br /> EXT. APN{ LAND USE APPLICATION# <br /> 0� 6-3�a �b im <br /> PHONE 02 E.T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> IRECl1ESTOR G/alle �eo�� Fri CHECK If BILLING ADDRESS <br /> Busu Ess NAMEbb%T. <br /> HOBS Or MAILING ADDRESS p0 <br /> F � <br /> 1 ,2,A <br /> CITY STATE 1 ZIP qC-11 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL ws. <br /> APPLICANT'S SIGNATURE: DATE 3�/ �� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAIWR ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY 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: NED <br /> comasors: i%AR 11 400 <br /> SAN JOAQUIN COU <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME <br /> ACCEPTED BY: EMPLOYEE#: )� DATE: <br /> ASSIGNED TO: EMPLOYEE#: 7111MA2 DATE: <br /> ,e <br /> Date Service Completed (if already completed): SERVICE CODE: ZZ Z P I E:Zbo <br /> Fee Amount: (Gjb Paid 6 (cJL _D"o Payment Date 3 I( O g" <br /> Payment Type Invoice# Cheek# l LD 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2007 <br />