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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �j l�21f <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY DAME t7i <br /> SITE ADDRESS 1 ��iIH'G, (✓%�VI�EryJ�Z ' <br /> Street Number Direction �J/ Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) i��" FV')✓r'�t'j " 1�_0 <br /> Street Number Street Name <br /> CITY '�f 4M 1.r" STATE �5VA A ZIP Qpti�3 y� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> fj6 7-Zbo —X PA - VC,, Z;7-1Q-70 - S - 7,40I <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A45 <br /> ✓ CHECK if BILLING ADDRESS <br /> BUSINESS NAME I��(��/pJ L M a i j�� PHONE# �_ —/_6- �� E <br /> HOME or MAILING ADDRESS r" FAX# G <br /> (zo``I) <br /> CITY j�I�t 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 <br /> or 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 and FEDERAL laws. - <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/i1IANAGER ❑ 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> PAYMENT <br /> COMMENTS: /Dq �! _ RC <br /> UElvtu <br /> ,/Z�T�►`Ll. =?/( !/ D 7� DEC 2 9 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HFALTH DEPARTMENT <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: SCJ E <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Q ` Amount Paid © Payment Date 0 <br /> Payment Type Invoice# Check# 2 ` ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />