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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> type of Business or Property FACILITY ID#, SERVICE REQUEST# <br /> l <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS O <br /> Gha <br /> FACILITY NAME <br /> SITEaA/D1DRESS /In I(�anj� C-JJLt-r YJ� 1 ✓�� <br /> 1-\LJ� Street Number Direction �-�1 Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY Street Number Street Name <br /> STATE ZIP <br /> PHONE#1 EXT. APNIf LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOSDIsTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 CoMrodcf:p <br /> CHECK If BILLING ADDRESS <br /> J L PH N # <br /> BUSINESS NAME �t5 61 - 7 EXT. <br /> FAX# IGHOME or MAILING ADDRESS / <br /> (2m ) 4t <br /> ol <br /> CITY C 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 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. ,n / " ��) <br /> APPLICANT'S SIGNATURE: �Yyn �Oy K , DATE: C& (3 (C1.9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �f{/h(-,)e I JL,1T( <br /> If APPLICANT is not the BILLING PAHT}'proof of authorization to sign is required Title <br /> AU'T'HORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Q^, ,t/ST <br /> COMMENTS: Tom\ 1l zo� �L�t 1 hoz 4AYI�rCnlPk-7 ) I.�(1 ✓�;5 r9 C�I v4il 5fx15 <br /> `lJ h�I\I v ��K , RECEIVED <br /> 1 DEC 18 2008 <br /> ACCEPTED BY: ENVI PfaY DATE: <br /> ASSIGNED TO: I f EMPLOYEE#: DATE: " <br /> Date Service Completed (if already completed): v SERVICE CODE: / P l E: v�0 <br /> Fee Amount: —"� `^ Amount Paid IIK 3)s- O Payment Date �I o <br /> Payment Type ✓ Invoice# Check# (� Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br />