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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -e bqL)ogS(-pAk r-L(00011gfo SNOV <br /> OWNER/OPERATOR <br /> ^ H 8S ^v 1- / <br /> FACILITY NAME CHECK If BILLING DRESS <br /> r\ ��t C r if <br /> SITE ADDRESS 4 2 0 ' OS /" '7-F <br /> F fO R 7�� <br /> Street Number Direction Street Name City 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 /> (flo) 3Y3 65316 219,�3(20W <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) I 00S <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR nn CHECK If BILLINGADDRES <br /> K� S <br /> BUSINESS NAME © _ � P-a# 3 � 6 / ExT. <br /> ��?V C— %i-V7 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE i, /1 ZIP r� U <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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required l'irf c <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S PA <br /> COMMENTS: <br /> AUG 31 2p1� <br /> ��OAQUtN CUA� <br /> ENtie�TH DEPp�TMENT <br /> ACCEPTED BY: lJL EMPLOYEE#: I DATE 2I . n <br /> ASSIGNED TO: EMPLOYEE#: (> DATE: _.31 <br /> Date Service Com leted (if already completed): SERVICE CODE: IQ(oP/E: 0 '�I <br /> Fee Amount: Amount Paid `SZ Payment Date '9 31 1� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />