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SAN JOAQ[ COUNTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sRc07 3 <br /> OWNER/OPERATOR <br /> CHECK IT BILLING ADD <br /> FACILITY NAME <br /> i <br /> SITE ADDRESS �,� ([ n�-��� <br /> 0 ISIM. me.r StrSe n. e." �" Ct-t J-,Wp—A" -4 Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP Ibq yM <br /> PHONE#1 ExT• APN S LAND USE APPLICATION# IVO <br /> ( Dov <br /> PHONE#2 En. SOS DISTRICT L AtTOY CO S <br /> ( ) NE4( �0 DDu <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Bus INE765 NAME J PHONE# En. <br /> l <br /> HONE O�r MIt NGADDRESS �A%# ) <br /> CITY,? / kin= STATE C ZIP 5� <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 applicatii In and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATE Id FEDERAL laws. <br /> APPLICANT'S SIGNATUIREEX DATE: G <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: U�(„Q_{'Vl•,Q,fit t <br /> COMMENTS: c��-oma. mus( a 4,.� "r- <br /> C3�.s�., a� /.t•�S <br /> �et� laa ✓M/ �ntc -c�ccm � ��rfev <br /> S-0-0 dt <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �/ EMPLOYEE#: DATE: r rz- /� <br /> Date Service Completed (kf already Completed): SERVICECODE: I ® PIE: 230 <br /> Fee Amount: 3 a, - Amount Pai 34/0-0CJ Payment Date "OV/s— <br /> Payment Type Invoice# Check# 772n Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />