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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> /0 IA4Y 4 ZG -- CHECK ifBILLING ADDRESS r� <br /> FACILITY IUAMF. 15 �l , l <br /> ��hGd ¢^ <br /> SITE ADDRESS-, y _ <br /> /0 <br /> Siraet Name ci _,Zio Code <br /> }{OME or MAII-m ADDRESS (if Different from Site Address) <br /> Street Number Street Narne <br /> CITY STATE ZIP <br /> PHONE#1 a EXT. APN# LAND USE APPLICATION# <br /> a�) 'V00-7/1y <br /> PHONE#2 Ex-.. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR rr CHECK If BILLING ADDRESS <br /> ✓O4-t4� TJY/7CU <br /> BUSINESS NAME / PHONE# ExT. <br /> HOME or MAILING ADDRESS�� FAx# <br /> 903 �wi� ( ) <br /> CITY CSTATE /?4 Zip 9 a2 <br /> BILLING ACKNOWLEDGEEtfIENT: 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 ide tified on this form. <br /> I also certify that I have prepared €s app'cati and t e work to be performed Will be done in accordance with ali SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stand rds,STAT a FE A aws. `"'] �7 / <br /> i�PPLICANT'SSIG[�ATliriE: DATE: ( v� 1 <br /> PROPERTY BUSINESS OWNERJ <br /> ERATOR I AGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 1S not tLL1NG PARTY,proof of authorization to sign is required Title <br /> AUTHORiZATION TO RELEASE FORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, herebv 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. PAYMENT <br /> TYPE OFSEPVICEREQUESTED: � I iai <br /> COMMENTS: � ` nW O , n" / 1„ -*Jn , <br /> JUL 2-5 Z016 <br /> SAN JOAOUIN COU Til <br /> ENVIROII <br /> REALM DEPARTMIt"T <br /> ACCEPTED BY: EMPLOYEE#: DATE.- <br /> ASSIGNED <br /> ATE:ASSIGNED TO: lei���2 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): Z SERVICE CODE: C��?J P!E: 1 <br /> Fee Amount: • Amount Paid ;Z © Payment Date 7 a'ZS rG <br /> Payment Type Invoice#i flte�lc <br /> *719'� Received icy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />