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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r-A D -7 )U � S 0O 770069- <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> .740 Ni�a��LfL <br /> Street Number Direl tlon Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> lr l <br /> {+ Street Number Street Name <br /> CITY !� STATE /-i' ZIP r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( q25- 6,1-11)--S7-0 o <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> 'J CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# f EXT. <br /> FoV-ree-srTTG s�oas(az.,�-ns�r—� 910 �v9� ���/ <br /> HOME or MAILING ADDRESS ga--7q r FAX# <br /> CITY fa-k- � �- !r` STATE C' zip <br /> BILLING ACK--NOWLEDVGEMENT: I, the undersigned property or business owner, operator or authorized agent of <br /> acknowledge that all site and/or project sped ONMENTAL HE TH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed tome or my business a�tj <br /> n this form. <br /> also certify that I have prepared this applicat the work t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE aL law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER © OTHER AUTHORIZED AGENTIfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 asse ment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 Soon as It Is available and at the same time It i o me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: _ FoU L Own CNW—1G V 1 >rJ <br /> COMMENTS: Hrn V 0 of ' 20�� <br /> 1' j IV. 'sAil/,10 <br /> HE7-11 UM8 dUlyn, <br /> N <br /> H bEPp�MINT <br /> ACCEPTED BY: F, Kan)C-Y-- EMPLOYEE#: DATE: 5 3 1 J 7 <br /> ASSIGNED TO: f I s S M EMPLOYEE#: DATE: C, 3 i 1-7 <br /> Date Service Completed (if already completed): SERVICE CODE: a 3 P l E- loo ( <br /> Fee Amount: o <br /> 0 D Amunt Paid 7 by Payment Date <br /> Payment Type a Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> I <br />