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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type o Business or Property <br />E,SIP.)1e4a7-- <br />FACILITY ID # SERVICE REQUEST # <br />,SListiii 5 <br />OWNER / OPEPpTOR 1 \ <br />T(, 1.U a -64 CHECK if <br />L L 1 BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS IQ .iecj j <br /> mber Dition A- l 10h Street Name (2'6( \ Pqp,r` Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />bi V), i _) ti Kr t-towE Actit_ Street Number Street Name <br />CITY A A , , _ STATE ZIP <br />PHONE #1 EXT. <br />-1 <br />b <br />APN # <br />AAL4F3-0—:77-441it. <br />LAND USE APPLICATION # <br />PHONE 42 EXT. c9 <br />( ) , c-c6V-9S /'; 4 ç3 DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />661'/4 <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />( <br />) FAX # <br />( ) <br />CITY <br />7 <br />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 Of <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this a <br />COUNTY Ordinance Codes, Standard <br />APPLICANT'S SIGNATURE. DATE: <br />PROPERTY BUSINESS OWNER OPERATOR / MANAGER EJ OTHER AUTHORIZED AGENT El <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provicAd to me or <br />my representative. 4' - • <br />TYPE OF SERVICE REQUESTED: £5,-i( 6.6„4-cm,(1 -ST-4/P ‘iiczceit <br />COMMENTS: FE8 <br />0 5 <br />sAN ja.1 _ • <br />h4Allf/ROTA/ COor <br />t7-118'iP AIFAIL ' wziv <br />ACCEPTED BY: <br />4/tn.- <br />EMPLOYEE #: DATE: <br />A <br />ASSIGNED TO: AP-14-E49 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PlE:yr604 <br />Fee Amount. <br />. ci <br />h -2)111 tO Amount Paid 30471-: ()-75 Payment Date <br />Payment Type (74,/ Invoice # Check # ft 4f Received By: zip_ <br />t the work to be performed will be done in accordance with all SAN JOAQUIN <br />laws. <br />/ <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)