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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ':;,QC,0731C <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> SCJ — <br /> FACILITY NAME <br /> N 0 F' i O S <br /> SITE ADDRESS, ," dt <br /> AGSM �-C� /�-t�/�4 ��C,�- 53 6 <br /> eet Num er DirectionStreet Name CI Zi Code <br /> HOME Or MAILING ADDRESS (if Different from <br /> TSite Address) <br /> - l- ` (•-` ,N O�� `�\ R, Street Number Street Name _ <br /> A" STATE _ ZIP <br /> m <br /> CITY p, IST C(�- C A- clzl:�-AG <br /> PH-NE#1 EXT AP I# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE i <br /> ( ) I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO-R� <br /> 1 CHECK If BILLING ADDRESS <br /> ExT. <br /> BUSINESS NAME PHONE# <br /> HOME DDRESS FAX# <br /> CITY /L(��1 STCTE� �h-�; <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 ce, ify 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 a FEDER6L-laws,- <br /> APPLICANT'S SIGNATURE: _ DATE: C/A .S <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 available and at the same time It IS prided to me or <br /> my representative. _a 4 <br /> TYPE OF SERVICE REQUESTED: Onlq Ay�+— cISwI fghdy-i <br /> COMMENTS: �L 0 Ob OJV <br /> ACCEPTED BY: _ I EMPLOYLc#: Y� DATE: 1 �� <br /> ASSIGNED TO: RIZ,LV/i- e'v\ EMPLOYEE#: — DATE: elwf�-- <br /> Date Service Completed (if almady completed): SERVICY.:Co'::--: L�j'f C�` i P I E: <br /> Fee Amount: '42�1520 .. Amount Paid I yment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />