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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UrPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#_ <br /> <ja?�D73r( 'J <br /> OWNER PERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME / GQ- / <br /> MSS DRESS L/r' 1,/,vr'��y_�/7// <br /> D Street Number Direction kkJI� S" [rdef Name Z'i�otle� <br /> HO E or MAILING ADDRESS (If Different from Site Address <br /> Street Number Street Name <br /> CITY STATE <br /> n 0 <br /> PHONE# EXT, APN# ND USE APPLICATION# <br /> (?09) 33Y3 <br /> PHONE#2 EaT• BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ��� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEExt. <br /> La co-,,,a 6L Cr /JPS Pyp <br /> HOME Or MAILING ADDRESS FAX# I <br /> CITY L ST TE 1 <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 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 FE ERAL laws. (� <br /> APPLICANT'S SIGNATURE: J/()y/p� /A" DATE: /J <br /> PROPERTY I BUSINESS OWNER Ir 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 INFORMATICiN: 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pylded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: O <br /> COMMENTS: <br /> SAN✓O 5?0>6 <br /> NF LNy o0 AR OU rr <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: j 5 <br /> Date Service Completed (if alt ady completed). SERVICE CODE: PIE: <br /> Fee Amount: f 30-OV Amount Paid /36,,, rj Payment Date <br /> Payment Type Invoice# Check# Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />