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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Moor) 7yacy' 0 c6��a2/ <br /> OWNER/OPE OR <br /> CHECK If BILLING ADDRESS E] <br /> 1 <br /> SITE ADD SS j t ` ) , ,1 ^ Q� 7�^ 6 _ <br /> S IhGI t r D1..tIon v tNd e lJ\ (YI oCef�e/ <br /> 1-19ME Or MAILING ADDRES If Different from Site Address) <br /> Street Number Street Name <br /> CI C9 <br /> IP . <br /> PNOJE#1 /�Q _ Exr APN# LAND USE APPLICATION bP <br /> ( N/VJ,Z lfJ/ "—•-`EXT,'YL'7"I BOS DISTRICT LOCATION CODE <br /> 83�- 3M1 Jfk— 11 7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESMick- <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME x'10lt / los Jv!P �J /F1xT' <br /> l l/ "?(0 <br /> HOM Or MAILINGADDRE �� F # <br /> ( ) <br /> CITY ZIP <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 thisform <br /> I also certify that I have prepared this applicati and th t'f rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stand s <br /> APPLICANT'S SIGNATUE� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �Vyf/r <br /> If APPLICANT IS not 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 as Soon as It Is available and at the same time It Ib(7V to me or <br /> my representative. % •IRv'i <br /> TYPE OF SERVICE REQUESTED: Vo :on OSS <br /> COMMENTS: 84N✓0 <br /> FNV AQP/N <br /> NEyGTH o) R �N)Y <br /> ACCEPTED BY: Sed EMPLOYEE#: DATE: <br /> ASSIGNED TO: til 'S`j EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: _0 <br /> Fee Amount: i'7J- C Amount Paid3 Payment Date 17 <br /> Payment Type ��_,Invoice# Check# RecdivedBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />