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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST #, f <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAcIQTYNA EE <br /> Zflod iYa SQ.uu a (u�i $ ' <br /> $ITEADDRESS J �� l � 576 <br /> 5mber Direction Siraet Name (cit ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) Z S-C? � ,f-kre /or -Glvd , <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 61 S� :172 <br /> PHONE #1 ERr• APN # LAND USE APPLICATION <br /> (208 ) 3 Y5`54 LJ1 11 <br /> °� <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) �(VC 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / <br /> kp6qh �GJ it5 C /0 f CHECK If BILLING ADDRESS El <br /> BUSINESS NAM I PHONE # Exr, <br /> 2- ` 70 <br /> HOME Or MAILING ADDRESS <br /> CITY <br /> n STATE ZIPc� G, 7 <br /> �'i';k:, �x H e. +'C Z '. <br /> BILLING ACKNOWLEDGEMENT: 1, 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, SfandardS STATE and FEDERAL laws <br /> c., <br /> APPLICANT'S SIGNATURE: L 'rf—'A e �� DATE: I 23 "24J <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT f (r(31C 9 Q�•yi3 e,( <br /> ff APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 i5 provided to me Or <br /> my representative. '..... <br /> TYPEOFSERVICE REQUESTED t, : �5 O / f'" ` 1 � Y <br /> COMMENTS: V ''.,... <br /> �® <br /> S'4 N JO 2 y ZO?o <br /> NEgGTN p0NMUOUN] y <br /> ACCEPTED BY f 'CC:` 4' j /")y° mss ,..,„ EMPLOYEE DAT . ,.�_ ' ,r%�',.f <br /> ASSIGNED TO. } ? L f} EMPLOYEE M DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: L Amount Paid < '. .�} . , D// Payment Date <br /> Payment Type /` Invoice # Check # 2 Received By: <br /> EHD 48-02.025 SR FORM (Golden Rod) <br /> 07/17/08 <br />