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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business o�erty FACILITY ID# `f,�.SER1V�ICE REQUEST# <br /> OWNER/OPERATOR <br /> 0, <br /> n CHECK if BILLING ADDRESS <br /> FACILITY NAME I / <br /> SITE ADDRESS Z 2 0 i-fsa t lq!52qo <br /> Street Number Dir 1,V y time I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> r1 � Street Number IN VStrast Na W <br /> CITY W U v d YJV d C-. STATE CZIP ? S/ <br /> PHONE#1 APN# LAND USE APPLICATION <br /> (M) 3 7f <br /> PHONE#Z Ex*. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOft 1 1 l^n <br /> CHECK if B1LLlNG ADDRESS <br /> BUSINESS NAME --D Jn e `^ P 0� E <br /> HOME.Or MAILING ADDRESS (/ t//�� �/,/ / FAX <br /> CITY a STATE ZIP �J <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 FEDERAL laws, <br /> _�,,.. s/ i. <br /> APPLICANT 5 SIGNATURE:; 't DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER i] OTHER H RIZED AGENT <br /> ff APPLicAmT/s not the BnLrNG PARTY.proof of authorizafton'to gn is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, i, the owner or operator of the property locate at the above <br /> site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assess %alion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is my representative. ( <br /> TYPE OF SERVICE REQUESTED: J <br /> COMMENTS: Sq/y JOq ?0�9 <br /> �NV/ QUlly <br /> co�H <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: Q'7 DATE: t <br /> ASSIGNED TO: EMPLOYEE#: 003 <br /> b DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE- <br /> Fee <br /> !E:Fee Amount: Amount Pat D Payment Date 7 <br /> Payment Typ ��� Invoice# Check# ��3��OS� R ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />