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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n�L��� ►-� JK �7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> i k s( <br /> SITE ADDRESS 7� ll `v_�/� "1 11 n <br /> 2—gUD Street Number Direction i T `Q<rDt St Name � �� Zic�Covde <br /> HOME or MAILING ADDRESS (If Different from Site Address) V(L`` , `\00� C-k l„ f <br /> Street Number JLJ�N StreeName <br /> CITY STATE IP <br /> c C'A 9 i <br /> PHONE#i EXT. APN# LAND USE APPLICATION# <br /> —(2M CM S-cl(o& <br /> PHONE#2 EXT. BOS DISTRICT -7LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> U t) CHECK If BILLING ADDRESS <br /> BUSINES NAME i0ft EXT. <br /> HOME or MAILING ADDRESS FAX### <br /> �Zockwoob ( ) <br /> CITY 1STATE,r k ZIP q <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 5u►i 2m 7-0 / 9 <br /> PROPERTY/BUSINESS OWNER CP OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tisle <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 <br /> my representative. VPA*f%"zf <br /> TYPE OF SERVICE REQUESTED: /1/f <br /> COMMENTS: i v N 2 4 2`01 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTPL <br /> HEALTH DEPARTM ENT <br /> ACCEPTED BY: li A EMPLOYEE#: DATE: o / <br /> ASSIGNED TO: Vt r EMPLOYEE#: DATE: [ l <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: �y <br /> Fee Amount: (�) 'GU Amount Paid Payment Date <br /> Payment Type Invoice# Me-tk# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />