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SAN JOAQUT-COUNTY ENVIRONMENTAL HEALTI- DEPARTMENT <br /> NW, SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I' fi 9a`' -2/ 57g jl�oo �,.3 s-7 / <br /> OWNER/OPERATOR <br /> � L� U CHECK If BILLING ADDRES <br /> KtZFACILITY NAME �"'� <br /> SITE ADDRESS. Sweat Number Direction �el7 ��(�5[reet Na/m/e 7 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (Zoq) yo(0gpq <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR07 GG.�� <br /> �.-/a� .,j y 7-50-7 CHECK If BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME / /' 'O D D <br /> HOME or A NG DR SS t ! FAX# n QD 0 /JD <br /> CITY STATE ZIP / <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,STA ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR ER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPttC.ANT is not tl ING P,41? pro 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 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: r�6 <br /> COMMENTS: RECEIVED <br /> SEP 2 9 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY / EMPLOYEE#: DATE: 4 Z <br /> ASSIGNED TO: /-l o k rS C A ��Z EMPLOYEE#: o/ DATE: -7491/// <br /> Date Service Completed (if already Completed): SERVICE CODE: s 23 PIE: / 600/ <br /> Fee Amount: —� Amount Paid Ii Payment Date / <br /> Payment Type Invoice# Check# 01 4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />