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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> K��4.0C1 fill <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> a oLt r�r�✓ui, <br /> FACILITY NAME <br /> SITE ADDRESS /✓� ^ ,r,/ JqT Z <br /> (� Street Number Direction t'I S rt ee�Name `� 1 ` Ci C de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> G� <br /> I ' Street Number Street Name <br /> CITY / g4 STATE ZIP ^2- <br /> 27 <br /> PHONE#1 ( ExT• APN# LAND USE APPLICATION# <br /> 3 zo —oS— <br /> —11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION DE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t <br /> 7'^^ /-t u� _� CHECK if BILLING ADDRESS <br /> BUSINESS NAME ' '1 1 (J� p # EXT. <br /> 0 -0 J 3 <br /> HOME or MAILING ADDRESS ^` O FAX# <br /> CITY5C-11 ( ( Cl STATE ZIP � <br /> C U lJ <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST E and FEDERAL ws.� <br /> ` c <br /> APPLICANT'S SIGNATURE: =fes— L� DATE: 3�Z2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT WL, 11,1 --Cd.z/)`,I / <br /> If APPLICANT 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Re��/ �� <br /> MqR ? , <br /> &"J0AQUiN CO N9 <br /> N Ty <br /> ACCEPTED BY: EMPLOYEE#: DATE: p <br /> NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Pai �� Payment Date <br /> Payment Type Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />