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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/OPERATOR <br /> K_A1 � CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Fond <br /> SITE ADDRESS 5 F/�' /`�ny�t� ���/' �[(�j � � }��y/� ��qy '(�(���y/�� C <br /> QSreet Number Di ion `�0 1(.� �l r lSIC 1Q2L C t/ ' -' '`LZip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> l Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> I � CHECK If BILLING ADDRESS <br /> I BUSINESS NAME JJJ^ O� P ONEt I EXT. <br /> I e/ l <br /> HOME IMAILING A ESS FAX# <br /> a�Y' ( ) <br /> CITY ^ STATE rtq 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 /> 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 �IZIP�rC� <br /> PROPERTY/BUSINESS OWNER Im PERATOR/MAN ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICAN IS n0 t e BILLING PARTY,p oof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS 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 ied to me or <br /> my representative. vi <br /> TYPE OF SERVICE REQUESTED: ` �� h V ;� <br /> COMMENTS: n WAI TO— Vt W Y2— "vY <br /> do <br /> 19 <br /> MFNT <br /> ACCEPTED BY: r�+ ,�AfJ I,l� EMPLOYEE#: DATE: <br /> ASSIGNED TO: Vr v Y 1 0 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z PIE: <br /> Fee Amount: LiS� „ Amount PaiPayment Date �S <br /> Payment Type i Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />