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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5,ftqz.2-z-�; <br /> OWNER/OPERATOR //�J77 <br /> / h-y I4 <br /> FACILITY NAME CHECK It BILLING ADDRESS <br /> / U C.. <br /> SITE ADDRESS Gy12 Z �G' �� �/�[^ �7 l/ /I G,Q��� N2 O <br /> Slreet Number Direction Street Name !n' '7' Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) Di - v / <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> LYee CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> C/[-/L N'G12 Zo9 931-1 37S <br /> HOME or MAILING ADDRESS FAT(# <br /> S3S� �6 /art e%kl4t) I4c1. (toy) `FI 2373 <br /> CITYS .O Y7 STATE ZIP q5-01-S7— <br /> BILLING <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 JOAQUHN <br /> COUNTY Ordinance Codes,Standards,STATE,!90 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: — DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 25, C I V I C.. ,(_`A/C-s✓e— <br /> IfAPPLICANTiSnOttheB7LUNGPAe7Yproofofauthorizationtosignisrequired 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. J p <br /> TYPE OF SERVICE REQUESTED:�C�/eW I/ ylart D s�� 5'u(�Su✓• !'[tty. /� ol� <br /> COMMENTS: / RECEIVED <br /> OUT 9 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: C)LA U EMPLOYEE#: p 3 <br /> 1011 07 <br /> ASSIGNED TO: a A r A r N 4- EMPLOYEE#: SS(0�1 DATE: t 0 q <br /> Date Service Completed (if already completed): SERVICE CODE: 3[,S P I E: <br /> Fee Amount: j q LAmount Paid 14 b Payment Date `0 O <br /> Payment Type Invoice# Check# �7 f.�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />