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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />\R007 5- 1 <br />OWNER / OPERATOR <br />1 2-9.-P CHECK if BILLING ADDRESS 0 <br />FACILITY NAME 4-) 1 \ <br />le—ozoL, <br />SITE ADDRESS ;544,, A I Vii— <br />3- 1.1q 0 — - street Number Direction <br />-SG1,CtA 61-9 t/1 U-10 <br />Street Name City ZiD Code <br />HOME Or MAILING ADDRESS If Different from Site Address) ).e., <br />1 7 (0 6-6/ , ......10mi-- CO 51L-T--t-1141-eet ari5 Street Name <br />CITY ZIP <br />PHONE #1 Err. <br />Qa-f-11-V5- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOB DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />_ <br />CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME ) - <br />PH , EXT. <br />HOME or MAILING ADDRESS FAX # <br />CITY STATE G4 ZIP fl <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 />APPLICANTS SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER El— OPERATOR / MANAGER El OTHER AUTHORIZED AGENT El <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 providea‘to me Of <br />my representative. naV EN I <br />TYPE OF SERVICE REQUESTED: .F00 d ve hick Tinsrthbn REcovE° <br />COMMENTS: 1 g ZulfC1 <br />SAN JOAQUIN COUNTY <br />ENVIR NOMENTAL T <br />KALT H DEPARTME <br />ACCEPTED BY: /31-n0a vt,emeni‹, CO\ EMPLOYEE #: DATE: ' ( (ri),) I i 6 0 <br />ASSIGNED TO: K60/0(/ a r rtz tire „c EMPLOYEE #: DATE: I/ / 0 /1(., <br />Date Service Completed (if already completed): SERVICE CODE: 1( ot,( i P /E: i Vo3 <br />Fee Amount: \t 1 CI Amount Paid Payment Date /7 <br />Payment Type ,.___ ,- Invoice # Check # Received By: , - <br />EHD 48-02-025 <br />07/17/08 SR FORM (Golden Rod)