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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I I <br /> OWNER IOPERATOR /� /� �� ��; CHECK IfB1LLINGADDRESS <br /> � <br /> FACILITY NAME \// /j/J <br /> 1 050 -�= <br /> SITE ADDRESS /!fj a <br /> Street Number Dlrection Street Name Ci "! Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)'Igwx sw <br /> Street Number Street Name <br /> CITY „/w.7 STATE /B ZIP <br /> PH NE#1 (f i/►' 7 APN# LAND UCSEJT PLICATION# <br /> l ) X70-76 7- des=Oda-�� a3 - <br /> I PHONE#2 EXT. <br /> BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> I REQUESTOR <br /> /O/J/40;'/�� CHECK ff BILLING ADDRESS L <br /> BUSINEss NAME P E EXT. <br /> ��//®� fur ) 33-x- <br /> HOME OrMAILING ADDRESS /-�P oX =.Zigo <br /> CITY/ STATE ZIP 4 � <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 <br /> r <br /> or 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 and FED €,laws. <br />' APPLICANT'S SIGNATURE: DATE: -7 l q11 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGEN'a <br /> IfAPPLICANT is not the BELLING PARTY proof of authorization to sign is required Title <br /> I 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 JOAQUfN 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 /> r TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �' PAYMENT <br /> 7 <br /> JZ7/0 �/y/� RBCIEIvBD <br /> JUL 14 2010 <br /> SANJOAQUIN COUNry <br /> ` ENVTRONMEXrAL <br /> H <br />` ACG TED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE; <br /> Date Service Completed (it already completed): SERVICE CODE: 'Z�— 2,2-, p I E:2& <br /> Fee Amount: Amount Paid Payment Date r (� <br /> Payment Typec— Invoice# Check# t Received By: �I <br /> EHD 48-02-025 <br /> REVISED 11117/2003 1 SR FORM(c3plden Rod) <br /> �I <br />