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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> OWNER/OPERATOR G CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 937-6 Sugar Rz,&,J Tri C L 953o U <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) cl/_n "76 <br /> Street/Number Stree Name 7 <br /> CITY J�+ STATE //61 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION#-7 <br /> / XJ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR j <br /> F6 <br /> ,/ SC l l CHECK if BILLING ADDRESS E] <br /> S, <br /> BUSINESS NAME (J1V \e (((,����( \ PHOPHONE# ��J� EXT. <br /> e <br /> HOME Or MAILING ADDRESSn f, 5rv� I FAX# <br /> 0(� ,� GI t ) <br /> CITY b ck4zo <br /> STATE c' <br /> A ZIP —6-19© <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 ;IJFEDERAL laws. <br /> APPLICANT'S SIGNATURE: �r� DATE:�f <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the Same time It IS prq{jC18d to me or <br /> my representative. 11 <br /> TYPE OF SERVICE REQUESTED: t!? ( e� ( / <br /> COMMENTS: N <br /> ��IY � <br /> J <br /> y FNV°� OQ1 9 <br /> �TyOFNCO pq FT T,q� <br /> 7 / M <br /> ACCEPTED BY: �� EMPLOYEE#: o DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: vv <br /> Date Service Completed (if already completed): dl SERVICE CODE: z23 P15: q)-0 <br /> Fee Amount: Amount Pa 3D (� Payment Date <br /> Payment Type /17 t Invoice# Check# lqRecei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />