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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1--o � TI"'r�( G bblq oao <br /> OWNER/OPERATOR <br /> 1 a CHECK if BILLING ADDRESS <br /> FACILITY NAME L G►` <br /> E <br /> SITE ADDRESS 7-3 C, Z <br /> Street Number Direction Street Name CI Zi Code <br /> HOME or <br /> MA LING ADDRESS (If Different from Site Address)C. <br /> f Street Number 1/V J Stre'e[Nvame <br /> CITYs I 1 STA T!- <br /> ZIP�'J <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> —]PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 54 k-7 — j � CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# !1 <br /> HOME or MA ING AI!RESSn / ( )AX# <br /> ,LTJ ��F -/Y <br /> CITY S G 1 � I <br /> STATE 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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,S TE and FEDERA laws. // # <br /> APPLICANT'S SIGNATURE: – DATE: 7 t�C� _o M <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. ` /n ,' <br /> TYPE OF SERVICE REQUESTED: � V e k c j-c <br /> COMMENTS: <br /> APR 2 U 201 <br /> SAN 10A CO <br /> I L( C l-I NEACT11 o�ARTME n' <br /> Orff r I 1-1 4 T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �Ol^r �', � EMPLOYEE#: DATE: 2G r <br /> Date Service Completed (if already completed): SERVICE CODE: �(�� PIE: '( 03 <br /> Fee Amount: QV )o L�/ Amount Pai so, OD Payment Date <br /> Payment Type 'y Invoice# Check# Received B <br /> Y Yp _ Y:, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />