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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> SEP <br /> ��5) <br /> OWNER I OPERATOR 4J 1 C 7/t/X/T 6.e_ C4_:�4e,rC `- <br /> CHECK If BILLING ADDRESS <br /> � <br /> FACILITY NAME / <br /> SITE ADDRESS 5 `I ' `n/`,cp <br /> 0500 m D e t 7T>rekC,� 9 d <br /> Street Number Direction Street Name � Zi Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> it Number !' _(?4k/ _I� <br /> Sttreet Name -f*' <br /> CITY C STATE CA ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> has) S_777 <br /> aIL� -lbo-�� �-1 ?,SSBI - �'- 1 ��`3 � z_ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMES �J elt lam/ ) o PHONE# n n EXT. <br /> HOME or MAILING ADDRESS Q FAX# <br /> 3�I tJ 1�o Sf • ( ) <br /> CITY STATE cA <br /> ZIP )6't /J <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, STATE a431t FEDERA aws. ��l <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 Tirle <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is proviiAl to me or <br /> my representative. �7 Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �r� �JUN <br /> J � � �O <br /> NE� R01 f,OLIN <br /> H OFpgR MSN <br /> ACCEPTED BY: EMPLOYEE M �yJC DATE: /(,L ZD <br /> ASSIGNED TO: EMPLOYEE#: v�[ ^ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: s /� PI E: LL11-n <br /> Fee Amount: Amount Pai 30 ovD Payment Date lc f <br /> Payment Type(? Invoice# Check# 7'Lq� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />