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SAN JOAQQCOUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> 1 Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> IsS ' <br /> C <br /> J K � � CHECK If BILLING ADDRESS <br /> qqq II 11 4+ <br /> FACILITY NAME , <br /> SITE ADDRESS , ^n" eCaT�c- <br /> r; <br /> Street Number Dfrection Sr 1 t�� Street Name ci I Code <br /> ' <br /> HOM Or MAIIING ADDRESS (If Different from Site Address) Street Number J �'`�R U�_Street Name <br /> CITY T ZIP <br /> n �QC 0"' J? <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> { ) tw H09 -193 irg " <br /> PHONE#2 Exr• <br /> �3 f1�yy nn B05 DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 0;0q 2 1' -- CHECK if BILLING ADDRESS <br /> BUSINESS NAME t PHONE# EXT, <br /> HOME or MAILING ADDRE§S Fax# <br /> `CIN AeSTATE ZIP <br /> LR lr' <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 /> also certify that I have prepared this application that the work to be performed will be done in accordance with all SAN JOAQUIN I <br /> COUNTY Ordinance Codes, Standards T n EDE AL laws. <br /> APPLICANT'S SIGNATURE: DATE: I t 2_1 <br /> / <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER OTHERAUTHORIZED AGENT ❑ t <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 JOAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It isrovided to me or <br /> my representative. PAYMEaT <br /> TYPE OF SERVICE REQUESTED: 0 0n RECEIVE <br /> COMMENTS; <br /> OCT 12 20th <br /> W 6�� <br /> SAN JOAQUIN CQUN-" <br /> ENV IFIOMENTAL € <br /> HEALTH t]EPARfrAENf i <br /> ACCEPTED BY: MeMArClof EMPLOYEE#: DATE: h jIn <br /> ASSIGNED TO: v-0 Re A EMPLOYEE#: DATE: Vu �Z' I Yui ; <br /> N � <br /> Date Service Completed (if already completed): SERVICE CODE: Sf PIE: <br /> Fee Amount: Amount Paid {� Payment Date I <br /> I <br /> Payment Type�'!�4A Invoice# Check# Received By:�� + <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> i <br />