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SAN JOAQ'COUNTY ENVIRONMENTAL HEALTH *ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> Sk5P <br /> FACILITY NAME MOAL' CN6-VyV by <br /> SITEADDRESS (Lr �vld5`�D�ILr✓ 2 L7 f�`gTH,�e 1� �33 U <br /> W y / Street Number Direction Street Name Ci Zip 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# LAND USE APPLICATION# <br /> 61L ) 7ef-16�7-�-- &fi <br /> PHONE#2 22 EXT. BOS DISTRICT LOCATION CODE <br /> 01:q �7 nc o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> PrT ���}Grc� CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEM0_5- ^�� � ' 6 Exr.( ),fe ko A/ PHONEw /66 <br /> HomF.or MAILING ADDRESS FAx# <br /> '< �/✓�GL/.v� Lf9w�' (9(b) gj 'S <br /> CITY s C2i77"e-h-' -,ATATE 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: DATE: 2c' /5 <br /> PROPERTY/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 availablend at the same time it is provicjed to me or <br /> my representative. /IJ <br /> TYPE OF SERVICE REQUESTED: oo Fc <br /> COMMENTS: -"44t 0,� �O3' JUN, <br /> UN <br /> '2SANo,yFq4ygQ H1Foo ��o4qoqToEV � <br /> 0A V <br /> Aq <br /> gD�Y <br /> T <br /> ACCEPTED BY: :n EMPLOYEE#: DATE: . <br /> ASSIGNED TO: :,,aaEMPLOYEE#: DATE: tt _ <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 1 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />