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SAN JGAQ OUNTY ENMO NTAL . ` ALTH . PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QCJV 6�7 <br /> OWNER/OPERATOR <br /> CHECKIfMLINQ AI22RES§ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number t tre, I Street Name l clixi o e <br /> HOME Or MAILING ADDRESS 44(if Different from Site Address) �/� t <br /> T-®• d S-0 I Street Number Street Name <br /> CITY JJ A-W 4,a'.�-L „ STATE ZIP <br /> C� w <br /> sit ill S- <br /> PHONE#'1 Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr• BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> eF--U �Z CHECK if BILLIN�i ADDRESS <br /> BUSINESS NAME Ci„V�CLV- Ing Orvlce S Co PHONE# ExT• <br /> M ®S 9 1 CoA <br /> HOME or MAILING ADDRESS FAX# <br /> CITYefJ _ L C� STATE ZIP q-D Z <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 <br /> or 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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT` Y 1 S �T <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title �ECE�vED <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the Q <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sit���1a�tctvseSJn1jnJV <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sat44ime it is <br /> provided to me or my representative. pAQtJW GOON <br /> n {- WAI- <br /> TYPE OF SERVICE REQUESTED: t ��1�r�j{ 1..{_.,(J lof i x ENTN pEp RTM� <br /> COMMENTS: }! F 0S p v Y'0. (�/ S D <br /> JUN 16 2008 <br /> ENVIROWENT HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> Le <br /> ASSIGNED TO: Ll EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date & <br /> Payment Type Invoice# ` s 2 Check# 3�7 Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />