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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0p S�29()--)6 <br /> OWNER/OPERATORb S SLL��e / ,S CHECK If BILLING ADDRESS® <br /> l�s.S�io e' LZ <br /> FACILITY NAMEA O MAIL - <br /> v/s� � P C �aX (� <br /> SITE ADDRESS [�/" mors�4, l L ! O <br /> re [Number Direction Street Name CiN ZI Cod. <br /> HOME ar MAILING;A7DDRESS (If Different from Site Address) <br /> .,f��.��0,/�a��Q Street Number Street Name C <br /> cITY�fi. STATEzIP <br /> PHONE#T Exr' APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT ©O� LOCATION CODE <br /> ( ) 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ CHECK If BILLING ADDRESS <br /> BUSINESS NAME WO LTD <br /> PHONE# 5 <br /> HOME or MAILING ADDRESS u FAX# <br /> Po. BUX 1`f2-9 ( ) <br /> CITY 1 _ y�Y-D TATE 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, STATE anCI.F/ IRAL laws. �/ <br /> APPLICANT'S SIGNATURE:-->-7 / DATE: 2 ` /e <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER 13OTHER AUTHORIZED AGENT R <br /> If APPLICANT i5 not the BILLING PARTY,proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me Or <br /> my representative. <br /> Ar <br /> TYPE OF SERVICE REQUESTED: L T <br /> COMMENTS: <br /> 7/Ls/zc01— 52c0 y 30"'V• /ly ilsy�+( jy - ,C1,�� <br /> 53/ <br /> ACCEPTED BY: MPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: PIE: <br /> 41 Fee Amount: Amount Pain ���vv Payment Date Z <br /> Payment Type Ll Invoice# Check# Receiv d By' <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />