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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#7A SERVICE REQUEST# <br /> S f2�73 OU <br /> OWNER/OPERATOR /J / / <br /> l/! r CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> SITE ADDRESS ////J _ //r/� <br /> 17/e7 Slmber Direction /f®Gl INJ 9Z' 0 <br /> HOME Or MAILING DDRE S.(If Different,from Site Address) v7// <br /> .JL Street Number J"Jllireef ame <br /> CITY TATEP53 r <br /> rO y <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( / <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J �- �© <br /> NCHECK If BILLING ADDRE55� <br /> BUSINESS NAME / 'I�4p L '�O PHONE# �� jz EXT. <br /> HOME or MAILING ADDRESS 1` I FAX# <br /> t ( ) <br /> CITY STATE ZIP R52splcl—') <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 /> 1 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERA?OR-I-MANAGE— R LJ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY proof of authorization t0 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provideQ,to me or <br /> my representative. �NJ'�/�, A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: y <br /> SA FP p 8 715 <br /> f�OQQ HIE C UN TY <br /> NE VINOf <br /> Ii nEPART L <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: J/I6`It, <br /> ASSIGNED TO: MGf(,(� j Nf�l�/I yVY EMPLOYEE#: DATE: P( I/()o/IS <br /> Date Service Completed (if already completed): SERVICE CODE: �p(p., PIE: LCOIJ-✓ <br /> Fee Amount: / (` 0 -60 Amount Pal6t' 1136,6 v Payment Date 7/7-5 <br /> Payment Type ✓ Invoice# Check# 5-00& Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />