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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> IyJ, 11 r r ` o-, CHECK If BILLING ADDRESS� <br /> Ff.....�....._ \ <br /> Ot <br /> SITESDDRESS <br /> W J�S � •Str¢CYt\CNap a 1\`�1 1Av/�`(v'�C S"\_JFCTSZ2iS <br /> Street Number DIrection <br /> Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 17�V/ Street Number AC tree a� <br /> CITY STATE / ZIP <br /> �a <br /> PHONE#1p EXT' APN# LAND USE APPLICATION# <br /> ( So) S- `l ' �S-9 "� I C, _ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 11( ) G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1`( 1 �I`�/��V �n C; CHECK If BILLING A00RE55 <br /> V O 1`rnJ lY 01, <br /> BUSINESS <br /> NAME PHONE# <br /> ^ <br /> Ex. <br /> `� 0, ISM <br /> SMS.S /te <br /> HOMEorMLNGAFA%# <br /> ISG ! tVRES <br /> CITY I\1 <br /> STATE ZIP "3 7 f <br /> I� � J To <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 /> also certify that I have prepared this applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST - - EGERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER ERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is Ot 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 a$ soon as It Is available and at the Same time It Isded to me or <br /> p�Vi <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S O �� •YA <br /> COMMENTS: <br /> NJ0'gQQpiry <br /> ?01� <br /> V1% C <br /> H�[THO'pq �O�UN�Y <br /> ACCEPTED BY: EMPLOYEE M DATE: C6 / <br /> /1''J <br /> ASSIGNED TO: LI EMPLOYEE#: DATE: 8.�/- I <br /> Date Service Completed (if already completed): SEMnCECODE: Q PIE: oZ <br /> Fee Amount: a0 Amount Paid /S Q Payment Date $✓3� <br /> Payment Type ) Invoice# Check# Keceived By/ .__ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />