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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rucks <br /> %R/OPFFATOR <br /> 1/I isclo h F CHECK If BILLING ADDRESSO <br /> FACILITY NAME 1 T <br /> sturcE aA r,elrnw <br /> SITE ADDRESS 5-)Her `t V .vlarc 9 455I <br /> Ip <br /> D�Q Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If DifferentfromSite Address) ..r r <br /> 541SI MoLLi i1 r—Ic Street Number Nollt[ CI�St et Name <br /> CITY STATE Zi <br /> L f0rc Ca <br /> PHONE#1 Er. APN# LAND USE APPLICATION# <br /> NIS) 6322 - 1612-PHONE#2 E%T. BOS DISTRICT LOCATION CODE <br /> t9d5) 437 �r 19 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> Past P;srio+�a <br /> BUSINESS NAME PHONE# EXT, <br /> Swce4 00111) Mellow gas) f> <br /> HOME Or MAILING ADDRESS FAX# <br /> -54s1 HOLI_if Ctrcic ( <br /> CITY t-%vCt MOrr- STATE (t 1 ZIP 111-166) <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 thisap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S AT <br /> a ndFEpfiRAL laws. <br /> APPLICANT'S SIGNATURE: P � DATE: 5^13 _ I fj <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, 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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SgN�O I�? <br /> ell tql <br /> ACCEPTED Y: EMPLOYEE#: DATE: <br /> ASSIGNED TO: / EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6�� PIE: O <br /> Fee Amount: / UU Amount Paid 130, DD Payment Date �/ <br /> Payment Type (/ Invoice# Check# psz-/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />