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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Z5500A 000 b q3ct a <br /> OWNER / OPERATOR <br /> ry / � ` CHECK If BILLING ADDRESS <br /> ( i/� � /t;/ <br /> FACILITY NA d / _ 1'A _ 001 <br /> 4 <br /> SITE ADDRESS &V0,v� Q 6 <br /> 62 6W7� Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN FLAND USE APPLICATION # <br /> PHONE #2 EXT. r!5 <br /> 77 <br /> 1 LOCATIONOC E <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR s ^ CHECK If BILLING ADDRESS <br /> /W <br /> BUSINES NAM PNE # Exr. <br /> r / <br /> NG , 3 <br /> HOME r MAILING ADDRESS FAX # <br /> � o x ami ( — <br /> CITY STATE ZIP d� 7 <br /> I 7 L <br /> i 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, ATE and FEDERAL laws , <br /> APPLICANT ' S SIGNATURE : DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT P§ �Ar� 77Zofes p� <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sigh 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 . <br /> TYPE OF SERVICE REQUESTED : 3 Z Tim T B7 '� 7 pr <br /> 8 lE <br /> COMMENTS : �� � 3/A �/ � v vv Ql STO ]� oe <br /> "/�, • (.�� Te�ST �cS22� t" 1U q l FJ !_L �/ CJ�j� r ���W <br /> SAN N OAQU11y C <br /> 01 IAI:m <br /> ACCEPTED BY : EMPLOYEE #: DA . TN <br /> LkIAAL vg <br /> ASSIGNED TO : �_ I91 V 1poey <br /> EMPLOYEE #: DATE : �yoozo <br /> Date Service Completed Aif already completed ) : SERVICE CODE : I q2 PIE : <br /> 03 <br /> Fee Amount: © D Amount Paid � (� Payment Date a- aL -v <br /> Payment Typedu Lie I Invoice # Check # p Received By <br /> EHD 48-02 -025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />