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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o7- D >1T" 1912 <br /> OWNER I OPERAT R / <br /> �11N� I" v yr�L �p ��.y /-P; CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �y,4M>�O �© �`,/ ,r h �/�_' <br /> SITE ADDRESS <br /> 1/00 GOO"C1jId x,)0— ys'.pC� <br /> Street Number Direction t et Na Ci Zi Code <br /> HOME or MAILING ADDRESS If Different from Site Address) <br /> /� � Street Number Street Name <br /> CITY v' STATES ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (9o) 900 J".378' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (9 ) a -, �? r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME 7 0 rPHONE# Exr. <br /> Y/i�tJp �a '✓ 00�.�70' <br /> HOME or MAILIG ADD SS FAX# <br /> CITY I/JAdn/7ry_� 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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE end F " ERAL c <br /> APPLICANT'S SIGNATURE: G- DATE: <br /> PROPERTY I BUSINESS OWNER-EC.I( PERATO /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: f jvICU t `'ty�l cc aY <br /> COMMENTS: <br /> s,4n,gpR <br /> EIy�,% Z019S.triN C <br /> yEALTy ONMFD UN)y <br /> ACCEPTED BY: EMPLOYEE EMPLOYEE#: DATE: <br /> ASSIGNED TO: S �/J�— EMPLOYEE#: DATE: 11 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 1 W3 <br /> Fee Amount: tv)2` Amount Pai i <br /> Ov Payment Date <br /> Payment Type , Invoice# Check# � 22 7S Re eivecl By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> fi�� 25210(o <br />