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SAN JOAQUIN RNTY ENVIRONMENTAL HEALTH DEPAec fMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> =L <br /> OWNER/OPER_ATOR 113 <br /> CHECK If BILLING ADDRESS13 <br /> FACILITYNAME � oa /^t <br /> SITE ADDRESS /✓✓/,�////rr ��'�•/'� 3Z¢e[Numhr; Dire�n -_� �� Stree[N�me ! a •�� �� �C �-� !de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 3 L� , �iy Street Number Street Name <br /> CITY TECH-- STATE ZIcP - P �•!V^ 5 3 /b <br /> / <br /> PHONE#1 1T• APN rY LAND USE APPLICATION# <br /> (gid;) /oar <br /> PHONE#2T BOS DISTRICT LOCATION ODE <br /> (� ) adg- 8ag���si _ �f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ^�, RGA <br /> n ^ 1- . ' h �� /� CHECK If BILLING ADDRESS <br /> BUSINESS NAME r`}' _ IZ`�' YI'A�/ /v�y�,_T/ _ _ PHONE# a� / / Exr. <br /> HOME Or MAILING ADDRESS ` ' FAX# A1C <br /> e � ' -AY— I ( ) <br /> CITU i STATE ZIP 53 3 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 IS / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER r OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. 11 <br /> Re <br /> TYPE OF SERVICE REQUESTED: ) (Q n PIP ny1� 'r <br /> COMMENTS: vk.•#V <br /> J(l,V 1 <br /> e 01 <br /> Sq 4 2011 <br /> ffE,NNWRaMJfVOIJrY <br /> R OCP4RL4f <br /> r <br /> ACCEPTED BY: EMPLOYEE#: DATE: -4-1/_ <br /> ASSIGNED TO: L 1111L0 EMPLOYEE#: DATE: Lw_�, 1� <br /> Date Service Completed (if already completed); SERVICE CODE: ZPIE: <br /> Fee Amount: Amount Paid 3 /d U Payment Date <br /> Payment Type Invoice# Check# IS/ Received by: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />