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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> / SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DO <br /> '� OWNER 1 OPERATOR y� <br /> �� /� e ze CHECK if BILLING ADDRESS El <br /> FacrurY NAME <br /> 4 SITf ADDRESS , 13 f I l 1 CI,.Yr, <br /> Streen.bar Direction Street Name CI Zi Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street ber Street Name <br /> CITY STATE zip r7 C o n c-Gt, o <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#2 E.T. BOS DISTRICT LOCATION CODE <br /> (Zn 323 3 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> '4NA 8A t A U� t ) <br /> CITY G f / 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 /> 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. rL <br /> APPLICANT'S SIGNATURE: r L DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/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 to me or <br /> my representative. AJ <br /> /,+� <br /> TYPE OF SERVICE REQUESTED: �UU n I [Jt 1b <br /> COMMENTS: <br /> N�rw ou�u�- A <br /> sAN �� 83 20�� <br /> H.A(p RpUA9�OU TY <br /> H p PAR NT <br /> ACCEPTED BY: elt4 [ fk- ()P�\ EMPLOYEE#; DATE: 3 r <br /> ASSIGNED To: GLffiO /�/� EMPLOYEE#: DATE: <br /> Date Service Completed (If (ready!comple d): SERVICE CGDE: 147 Qz� <br /> i <br /> Fee Amount: l C� Amount Paid/�!`dC� Payment Date <br /> Payment Type Invoice# Check# QO Received By: I <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />