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SAN JOAQUIIv COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> / SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE ST# <br /> � 2 yJ- 9 <br /> OWNER/OPERATOR n <br /> �t �UiS Ar nC1_ CHECK If BILLING ADDRESS <br /> FACILITY NAME T A&) 2(0 <br /> SITE ADDRESS l,G 1 ' r a�"`G �� S�CjCk+0t� 5X03 <br /> Street Number Direction Street Name gity i Code <br /> HOME Or MAILING ADDRESS /if niff­-•° --""_ _, `J�\ <br /> 1 1 2_1 Street Number <br /> Street Name <br /> CITY SVxiiek n CA STATE ZIP 01��O <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (2 ) SIS pig � �I�a L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR —yo <br /> s CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONNE# EXT. <br /> \ <br /> HOME or MAILING ADDRESS <br /> FAX# <br /> CITY STATE CA <br /> ZIP q seo <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ek�Set ��S DATE: 22 JMono �6 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ElIfAPPLICAN iSn t 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 assess tinformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS RR Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: mA R �✓ <br /> COMMENTS: SJ �N4 '1016 <br /> ilo� Tq�NC t(nq,� o� trill) <br /> PARTM�NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> AsSIGNED TO: t>a vi -Z EMPLOYEE#: DATE: _aa_ M, <br /> Date Service Completed (if already completed): SERVICE CODE: C). ! P/E: / 3 <br /> Fee Amount: cY� Amount Pal /3 0Payment Date ZZ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />