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�Cl SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> S � a <br /> OWNER/OPERATOR ��++ L-i�`�i.� <br /> Ml / v1tr�(f� av� CHECK If BILLING ADDRESS <br /> FACILITY NAME ^'t� ^W� A1+R <br /> SITE ADDRESS Q05oo J p y` O�1 r 9y�0`f <br /> Street Number Direction l l Street Name Zi Code <br /> HOME Or MAILING DRES (If Different from Site Addres <br /> Street Number (meq -C[J�' Street(Na�/me���vJ <br /> CITY / i� STATE ZIP <br /> cA <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> (p� ) 993-977-7 k) -ao 0 - I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORevw ^Gh) "CL/ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �: „J 1 PHONE# EXT. <br /> HOME Or MAILING ADDRESS ^ n �/ FAX# <br /> 3qRd <br /> VJ1 gr11:�/\ t ( ) <br /> CITY Seo IJL.KI STATE CA 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 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, STAT d FEDERAL I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 prqyIded to me or <br /> my representative. NajqQ'-I <br /> TYPE OF SERVICE REQUESTED: I ti J Ec <br /> COMMENTS: JUN <br /> sAnr�U/V y ?419 <br /> Fly 0AQU/ <br /> ON COU H �OFPgR r�Ni?' <br /> o FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ll ZV� <br /> ASSIGNED TO: EMPLOYEE#: DATE: C 1 <br /> Date Service Completed (if already completed): SERVICE CODE: —2� P1 : '� 2 <br /> Fee Amount: Amount Paid ��� Payment Date � 6 f 1 <br /> Payment Type Invoice# Check# 7 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />