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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtrARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#::A SERVICE REQUEST# <br /> (�. w <br /> -5f- 06?g <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FITY N E j <br /> V <br /> 72SFTE,ADODRESS _ _ -yam S - CAII OvC( S-toCkton CtS7-d7 _ _ <br /> Slreel''Number Direction Street Name Ci Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 3 D 0 O Y Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (44* 5G,1 - ci%I l N7,1 a6 63 <br /> PHONE#2 Exr• BOS DISTRICT —] LOCATION�DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CA V CHECK If BILLING ADDRES <br /> e - <br /> BU NE NAME PHONE# ExT' <br /> ! _ ) <br /> HOME or MAILING ADDRESS Fax# <br /> ( ) <br /> CITY O �STA 2—A ZIP . 5 z I <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 appAeaIq n {gnd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,Sk TE afid DI RAL laws. <br /> APPLICANT'S SIGNATURE: 7 I DATE: 12 - GZ C� 17 <br /> PROPERTY/BUSINESS OWNER OPE ATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY Proof of authorization to sign IS required _ Tide <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 as Ion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a$ soon as it is available and at the same time I I Or <br /> my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: 12 9.1 42 .Dn <br /> BEG 19 2M7-- <br /> COMMENTS: <br /> �Q I SAN JOAQUIN COUNTY <br /> (�16 LI CQJ'1 SP_- pla O 2 J 1�j-)-/O(�'(010 ENVIRONMENTAL <br /> iJ HEALTH DEPARTMENT <br /> ACCEPTED BY: �6 rn EMPLOYEE#: DATE: /q- <br /> ASSIGNED <br /> ,ASSIGNED TO: t�`t c a- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 1 Amount Paid I rj�_ Payment Date f�, j q, 1 '7 <br /> Payment Type C. Invoice# Check# Received By: <br /> 0 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />