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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Q (Z D58'7 $ 841 <br /> Type of Busin s or Property FACILITY ID# RVICE REQUEST# <br /> Ala <br /> OWNER/OPERATOR /t� ..///' �_�_I/ <br /> '-•re•r1N.7 �`r'V CHECK If BILLING ADDRESS <br /> FADILRYNAME <br /> SITEADDRESS 7536' �,r`F/G�E ��aGyr. / �l 9 <br /> StreMtW'nber Direction 'I(�' Slrect Name /'Citl/1f Z7f Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> L/ (0 SNtreeet Number Street Name <br /> CITY S�O CF SON STATE G� ZIP 9520 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# 7 j <br /> PHONE#2 EKT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EKT. <br /> HOME or MAILING ADDRESS FA%# <br /> CITY 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 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 ap I' all IT d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE d FE ERAL laws. <br /> APPLICANT'S SIGNATURE:: DATE: <br /> PROPERTY/BUSINESS OWNER VJ OP BATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PAR ,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 environmentaVsite assessment information <br /> l0 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. Con/t ,'7 <br /> TYPE OF SERVICE REQUESTED: CS V n <br /> COMMENTS: <br /> ACCEPTED BY: O EMPLOYEE#: - DATE: <br /> ASSIGNED TO: t EMPLOYEE III: DATE: 2 <br /> Date Service Completed (if already Completed): SERVICE CODE: I P/E: W r <br /> Fee Amount: C/ Amount Paid I S-Z Payment Data 5/3 2 7 <br /> Payment Type r'/' Invoice# Check# �'L L� b 8� Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />