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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> u L <br /> OWNER/ OPERATOR <br /> /✓JR. ,TOL/n/ 7R/NKL-E CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 21tVKLE AC7 FL iN G / <br /> SITEADDRESS -2-15-e-3 .S kQ SSOn/ T�C\ / .530y <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 02 SO O �e D. _ <br /> Street Number Street Name <br /> CITY STATE ZIP 3o"Y <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (MI) bio - 7ff4 023 - // - /S PA - 00000,e3 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS IT <br /> BUSINESS NAME t' J G PHONE# ExT' <br /> G�lESn/E G'ONILlLT/r\/( GG -/¢o� <br /> HOME or MAILING ADDRESS FAX# <br /> . © • box 3 d ( ) G6B-zs9 <br /> CITY L LIP e- STATE 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 biped to me or my business as identified on this form <br /> I also certify that I have prepared this applic on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST nd FWEVDEWS. / <br /> APPLICANT'S SIGNATURE: DATE: YO -Z 3-C?g; <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT YY <br /> If APPLICANT is not the BILLING PARTY proof of au orization to sign is required Title <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: 3rD/L fa/TA BtL U P T N!J /h E/VDm 9�LMIP:KIT <br /> COMMENTS: G 3a 08 ---s;— �•a�..�� RECEIVED <br /> JUN 2 3 2008 <br /> �Ja VY SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPART ME <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: '1/ PIE: <br /> Fee Amount: �' Amount Paid Payment Date <br /> Payment Type - Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />