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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busin I or Property FACILITY ID# SERVICE REQUEST# <br /> ZIA <br /> OWNER 1 OPE TORn <br /> CHECK If FILLING ADDRESS LJ <br /> FACILITY NAME <br /> SITE ADDRESS JVM4--' Cf��f <br /> SlreefNler Drrectlon -` Street Nam Zi Cade <br /> HOME or MAILING ADD ESS (If Different from Site Addres <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR CHECK if 1:3ILLING ADDRESS+ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADD s- � '� (AX# ' <br /> CITY STATE Lip <br /> BILLING ACKNOWLEDGED ENT: 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 p ication and that the work to be performed will be done in acro nce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard ,S ATE and FEDERAL laws. <br /> APPLICANT'SSIGNATURE: %' DXd <br /> PROPERTY/BUSINESS OWNER D OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENlir <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is requir Title <br /> AUTHORIZATION 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 andlor 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. �A 1(1l/1A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS; N 3 1 2007 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE. 1 ! <br /> ASSIGNED TO: i 1 fi EMPLOYEE#: ' DATE: l <br /> Date Service Comple (if already compieted): V l� SERVICECODE: <br /> Fee Amount: 1:4 J Amount Paid ' $CJ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-425 ,SR FOI]1N'{6oIden'Rad) <br /> REVISED 11117/2003 <br />