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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> wool(oH(65 S>2o67Lis�,4C) <br /> OWNER/OPERATOR <br /> GCk h\ _C CHECK If BILLING ADDRESS <br /> CILITY NAME C«�•w � �� �� <br /> TE ADDRESS S S�c� '�� Cl ?3 <br /> Street Number Direction (21 v V' Street Name 1 CI ZipCode <br /> OMA r AILING ADDRESS (If Different from Site Add r Ss) <br /> Street Number C Street Name <br /> CITY <br /> S � OCA f\ C TATE IP q� <br /> PH E#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> fn a E^I ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME J I^lA PHO E# EXT. <br /> ' l <br /> HOME or MAILING ADDRESS FAX# <br /> 3 CC.1 L)6 1 ( ) <br /> CITY O LYS U.� C . STATE C ZIP C J zC� <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATA=: ( ? <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 provided to me or <br /> my representative. no�1 ,�p T <br /> TYPE OF SERVICE REQUESTED: �DO v``!vy C/fl R� l <br /> COMMENTS: <br /> MAR 31 2 16 <br /> Sq fd A OUIN Cp <br /> HEALTH 0EPA N M Nry <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: —:7113 1/f fp <br /> ASSIGNED TO: ��� EMPLOYEE#: DATE: 9130u, <br /> Date Service Completed (if al,easy completed): SERVICE CODE: ��1 I P I E: l�3 <br /> Fee Amount: 13p•c� Amount Pain Payment Date <br /> Payment Type Invoice# Check# Received By: 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />