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SAN JQAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNERIOPERATOR -131 F>� Gly CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ��"' .rte <br /> $R 0 <br /> EADDRESS IWO� 'E_ 5-F477 /201- Z& G/NILE^/ 9523& <br /> SMel Number Direction Street Name co Zip Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Strael Numbe/ Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exi. APN# LAND USE APPLICATION# <br /> tzoq ) 931 - vl /OS-o�zo-Do7-31b <br /> PHONE#2 t� Em. SOS DISTRICT LOCATIONCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR u ((Le <br /> ✓T," CHECK H BILLING ADDRESS <br /> Er <br /> BUSINESS NAME rVl'}� l oiIAUd-PI q PHO -3 3` _ 1 <br /> 3 En <br /> FAX# 37,E <br /> HOME Or MAILING ADDRESS 0-7.� <br /> 3 <br /> C - CJU (ypq ) '�r <br /> CITY STATE CQ ZIP 4?S Z+t <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O TOR/MANAGER ❑ OTuER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY proof ojauthorizadon 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 REQUE9 ell 36kiR EC EI VE D <br /> COMMENTS: /CJS / .P� - ,D.�_ 3 r l� �M S� OCT 2 3 2007 <br /> 1%r/(Sxr� SAN JOAQUIN COON <br /> ENVIRONMENTAL <br /> HEALTHDEPARTME <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: 1 PIE: / <br /> Fee Amount: Amount Paid ,* 40 d Payment Date 0" <br /> d <br /> Payment Type <br /> Invoice Check 3L3 Received By:�.-0'e�7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />