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SANJOAQUINCOUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property J FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> O T l)J� J l� S CHECK If BILLING ADDRESS <br /> FAcKm NAME \J� C� �Y .0 <br /> SITE ADDRESS //// t <br /> / 1�d Street Number Direction Street Name6�/ %//{{��e�' f 2' V ' C II Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Cq/ Street Number Street Name <br /> CITY /� a STATE ZIPj-d r-, �D <br /> G a y <br /> PHONE#1 EXT. APN# LAND USE APPLICATION If <br /> I ) pa/- ��o - P dB- X71 � �ts <br /> PHONE#2 ET. BIDS DISTRICT LOCA N CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"* <br /> 9/-/ 3 7.Sf <br /> HOME Or MAILING ADDRESS �' '� FAX# <br /> v' -�3 -53- s- DIa ^i /t?aVCh Raf I ( ) 9,31— 2 <br /> CITY �(_ STATE zip /�5Z <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 appl' t 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, an;Z;� <br /> APPLICANT'S SIGNATURE: DATE: / dPROPERTY/BUSINESS OWNER❑ OPERATOROTHER AUTHORIZEDAGENT/O[I lyll- F—n9Y' . <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required N1Title 11 <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: /� IBJ s0i / ° PAYMENT <br /> COMMENTS: <br /> SEP 2 3 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L.( I A EMPLOYEE#: O ?� DATE: C1 <br /> ASSIGNED TO: IL.,(k.IJ A EMPLOYEE#: 5-34e DATE. Z G g- <br /> Date Service Completed (if already completed): SERVICE LODE: 5 ZZ PIE: <br /> Fee Amount: Z( U ) Amount Paid �; Payment Date R a,.3 U <br /> Payment Type �.' Invoice# Check# O s-0 Received by: <br /> EHD 48-02-025 .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />