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SAN JOAC1101 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G d pck ` 'W 7 1 9�C) <br /> OWNER OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE <br /> ALsb� o � ' ?� �� _ S-t0C �1 C�N "�520S <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ��+1 <br /> v Street Number - � Street Nam <br /> CITY SJ 06t::�iv STATt zipS <br /> � 'D2C <br /> PHONE#11 EXT, APN# LAND USE APPLICATION# 7 <br /> V? CA) 21 � � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> )nG �L(71l�e CHECK If BILLING ADDRESS ElBUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS510 9-end L� ve (AX# ) <br /> CITY S�C�G L�� (� STATE CA <br /> 1 zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operaato-r 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 /> 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 FEDERA laws. i <br /> APPLICANT'S SIGNATURE:" ' J G� /� DATE: ")2PROPERTY/BUSINESS OWNER OPER/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization t0 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 /> to 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. P <br /> TYPE OF SERVICE REQUESTED: k� IA R,c <br /> — - �C <br /> COMMENTS: p - � APR 10 <br /> X D 201 <br /> S <br /> ( AN JOAQUIN <br /> HE ENVtIjo,WL CO U ry <br /> AL7fl )EPAR ME <br /> r <br /> WAIL <br /> ACCEPTED BY: EMPLOYEE#: / DATE: J S <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERvICE CODE: o (7 / PIE: / <br /> F4 L- <br /> Fee Amount: Amount Paid "?670,d Payment Date `�� <br /> Payment Type Invoice# Check# Received By:. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />