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SAN JOAQUuv COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I 1'e `6 -� 520 7 '5 <br /> OWNER/OPERATOR <br /> I ` CHECK 1(BILLING ADDRESS <br /> FACILITY NAME J l�Cy Nx <br /> /n <br /> L l� <br /> SITE ADDRESS <br /> Street Number vl Dlrec,on ✓L��b Street ame i "1 I Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,(){ <br /> Street Number A ' Street Name <br /> CIN STATE Zig-. <br /> Sty <br /> PHONE11 ExT• APN# LAND USE APPLICATION# (� <br /> n� S <br /> PHONE#2 EXT. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME _/r I" <br /> l n .S LUZ PH}]N # /z _ _•CJ-C,/ EXT. <br /> HOME or MAILING ADDRESS I / FA%# <br /> t ) <br /> CITY t57,45 <br /> STATE 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 Charge$ 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 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: <br /> I /-p n . �1��P DATE: f �(p I 1 <br /> S <br /> PROPERTY/BUSINESS OWNER w 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, 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 provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> W,P6 2 15 <br /> APRu'N out. <br /> SAN'IOVAp ME IMS <br /> ACCEPTE Y: EMPLOYEE#: DATE:y/ <br /> ASSIGNED T0: j EMPLOYEE#: DATE: (,/- <br /> Date Service Completed (If already completed): SERVICE CODE: O�/ PIE: //Oa <br /> Fee Amount: �U Amount Paid ,CZ) Payment Date Lk <br /> Payment Type Cl Invoice# Check# Received By: @Pj_) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />