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G� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> C0 M or'A C'ON U• S I S�Q 0000 rL1 I 0 <br /> OWNIER / OP RATORl <br /> CHECK If BILLING ADDRES A <br /> D,) tCit r N 0 (lS >: (4 �F h%mmmi <br /> FACILITY NAME <br /> M , m L) (A az Imm ioa-< F <br /> SITE ADDRESS N W c 0,r M O /U 4A' o iq [7 ooh - E I(' ' <br /> SlreetNumber Directlan t r �rle� ep ��N1ftdWRIT ZIP Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> OX 33 tJ Street Number Street Name <br /> CITY STATE ZIP <br /> u �P' o G A <br /> PHONE #t EXT• APN # LAND USE APPLICATION # <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> A/I � AnK\ DCHECK If BILLING ADDRESS <br /> BUSINESS NAME ( / VV /P, ,4 7t "-t PHONE # El' <br /> C 1 121 If .�z o 0 � ' 3 <br /> HOME or MAILING ADDRESS FAx # <br /> � o o < A010 ( ) <br /> CIN ' , ^ O61< 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 /> 1 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, STATEn FEDERAL IaWS . <br /> APPLICANT'S SIGNATURE : �= � DATE : 3412z1 <br /> PROPERTY I BUSINESS OWNER 13OPE ATOR / MANAGER ❑ OTHER AUTHORIZED AGENT t✓ <br /> If APPLICANT is not the BILLING PARTY, 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 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 . <br /> TYPE OF SERVICE REQUESTED: / v ,/�� �� / (/z 4 /Cl iJ R NT <br /> COMMENTSO 0 <br /> 4 AR <br /> 1 <br /> SANtS 2 <br /> �0N 0 co <br /> Fpq /v7 � T �/ <br /> ACCEPTED BY: / yG EMPLOYEE #: DATE: /0 T <br /> ASSIGNED TO : �64 <br /> EMPLOYEE #: DATE : / 4 Z <br /> Date Service Completed (if already completed) : SERVICE CODE: / PIER <br /> 5 <br /> Fee Amount: `43? o C f ` Amount PPayment Date 2/ <br /> Payment Type �.�- Invoice # Check # / 2 8,3(Ft31 R' ec ived By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />