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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5rZ 0017/'7 '� 3 <br /> OWNER/OPERATn�p• <br /> V aIS g / `� ��-"�. CHECK If BILLING ADDRE T S <br /> FACILITY NAME L <br /> SITE ADDRESS L � ' <br /> Street Number I Direction Street Name Zi Code <br /> HOME Or MAI!me AnnpFcc w riff.—.f,--—._ <br /> Street Number <br /> CITY )) y/�� <br /> /v/1 /fl/?o STATS ZIP c) <br /> VP ONE#1 EXT. APN# LAND USE APPLICATION# <br /> 20(T-&74 k�b <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // y <br /> j�JL-L- G/�(,�� CHECK If BILLING ADDRESS <br /> BUSINESS NAME ., _ EXT, <br /> Ali t/�/✓C_CI� A- /c1//2cyrJd�YI�ZJT�9�— P E �—�� <br /> HOME or MAILING ADDRESS e-37 FAX# <br /> CITY i L�-�7 1 TATE ZIP9� J S— <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 ess as identified on this form. <br /> also certify that I have pfepar a plication and that the work to be performed will be do c dance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Sta ards,S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATU E: <br /> PROPERTY/BUSINESS OWNER ElOPERATOR/MANAGER El OTHER AUTHORIZED AGENT <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time it is provided to me or <br /> my representative. .q y <br /> cF �Nr <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: as <br /> H FSR QLA4 <br /> Noaky MY <br /> ok�74;t4 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: fj/JC C%� � EMPLOYEE#: DATE: -3 (E) I IS— <br /> Date Service Completed (if already completed): SERVICE CODE: v� PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# /1300 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />