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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or'Propert FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR n <br /> CHECK it BILLING ADDRESS LJ <br /> FACILITY NAME - <br /> SITE ADDRESS 033 <br /> Street Number Direction W Lt vS�treet Name Gi Zi Code <br /> HOME Or MAILING ADDRESS Different from Site Address) <br /> Street Number Street Name <br /> CITY f� y� STATE ZIP <br /> PHONE#'I EYT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT 1 LOCATION CODE <br /> � } i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO G �*/w . <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE �J a E"T' <br /> SA �L 0 a 0—') az <br /> HOME OC MAILING DRESS �/f, � FAx <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 ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, A and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / /� DATE: Jok 1114 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT i 4 /?a <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment <br /> information to 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: I/ E <br /> COMMENTS: <br /> OCT 2 1 2008 <br /> S' JQaQuuv COUNTY <br /> H rh CIN° ',L <br /> ACCEPTED BY: EMPLOYEE#: DATE C r (� <br /> ASSIGNED TO: C EMPLOYEE#: DATE: <br /> Date Service Complet d (if already completed): SERVICE CODE: PIE: 2-3 o d' <br /> Fee Amount: 6 Amount Paid Payment Date <br /> Payment Type �` invoice# Check#, 3 Received By: <br /> EHD 48-02-025 SR FORM(Q(?lden Rod) <br /> REVISED 11/17/2003 <br />