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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> o10 &FX T �(�NAi' C, /0A1 <br /> 1 CHECK if BILLING ADDRESS� <br /> FACILITY NAME F/�17- <br /> o <br /> 1'3R/ ff �� J,�I C�J�l ��V V ��4 <br /> SITE ADDRESS < ! 763 �(/ Cj F, >J i/� JS /� L <br /> Street Number Direction / Street Name CI ZI-�Code`r' <br /> HOME or `MAILING ADDRESS (If Different from Site <br /> '��A'ddr ss) <br /> ( 7 f 7 /,-/ `'1�r�/ S ' ` '/7 Street Number t-/ ( J Street <br /> CITY L C) L/^ / STATE C A ZIP <br /> PHONE#1 / �j z EXT. APNq#(� 6LAND USE APPLICATION# `f <br /> 7 - 31a 6 V%S 2200 A 0/106DS S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEC7 L FZi��� �j� s��/� l� PHONE# 3 6 7 36,-3 EXT. <br /> HOME or MAILING ADDRESS 1 / FAX# . <br /> 7 S 7 / ��'� S �2D . cwf� 36 1 <br /> CITY J/ STATE ZIP S Z <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 JO <br /> � �MEIVT <br /> COUNTY Ordinance Codes,Standards, STATE nd F RAL laws. PAYMENT <br /> �— l9 RECEIVED <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER PER T R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ MAY 0 6 2099 <br /> If APPLICANT is not t BILLING/ARTY,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 tT; 'QUIN COUNTY <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment in1f1A ONMENTAL <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to file o�EPARTMENT <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �. <br /> COMMENTS: REC <br /> I, ,,, ( u6 209 <br /> SAN JOAQUIN COL NTY <br /> ENVIRONMENTAL <br /> HEALTH DEpARTIN ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: O Amount Paid Payment Date 6 <br /> Payment Type Invoice# Check# I d Receive y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />