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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID if SERVICE RECNEST# <br />OWNER / OPERATOR <br />, e A ' e< 71-r- s- CHECK if <br /> <br />We o6 e .r_ 1 4 T 1 BILLING ADDRESS <br />FACILITY NAME' <br />//e' 77 14--a?1,2-<" <br />SITE ADDRESS f , <br />Street Number Direction <br />p, i).--i c, ..-k• /9 5 <br />Street Name #15-C/14.4441442) <br />Street Name <br />Zia Code <br />HOME of MAILING ADDRESS (If Different from Site Address) <br />Jo we.e ,.7/ <5 /2.0 ,o -/ 7 3 Street Number <br />CITY 2 STATE ZIP <br />PHONE #1 EXT. <br />(5l6) .1,. <br />APN # LAND USE APPLICATION # <br />PHONE #2 #2 Exr. <br />( ) II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UE <br />REQUESTOR <br />— <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY 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 />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: <br /> <br />DATE: <br /> <br />PROPERTY! BUSINESS OWNER OPERATOR! MANAGER El OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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 assessrriPA an to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is env <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />— . w i..-.1 <br />1;:e.37V ua1' , ..... 0 . /, a F . ES 0 4 201: <br />COMMENTS: <br />D-‘--t) V C r e AN <br />L'c)t)12- `fiffg--4 to -e--z#+- ‘ ono..i Ncou <br />HEALTH tyznENTAL ,,PAFINE, <br />ACCEPTED BY EMPLOYEE #: <br />ASSIGNED TO: i EMPLOYEE #: DATE. <br />Date Service Completed (if already mpleted): SERVICE CODE: 1 PIE:/O 3 <br />Fee Amount: / <br />96 <br /> Amount Paid ( 3D Payment D te <br />Payment Type Type ,i, Invoice # Check # I D o Received By: 14o, <br />Title <br />Ef-ID 48-02-025 <br />07/17/08 SR FORM (Golden Rod)