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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I; tee. 00 -779 <br /> OWNER 1 OPE TOR <br /> A A. 1 0. CHECK If BILUNG ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS r. � � �-i� �� <br /> Cllr <br /> Street Number ection /// <br /> ` �� � v t' 1 ' <br /> StreelNam CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Streef Name <br /> CITY <br /> STATE zip <br /> PHONE#1-2 / BIT. APN# <br /> (�Jf ,_j5l_ tOr c LAND USE APPLICATION# <br /> P NE#2 I L lfJ� VV SOS DISTRICT LOCATION CODE <br /> X )� 90 -7 O <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQuesTaR �I <br /> AIQQ CHECK if BILLING ADDRESS 1 <br /> BUSINESS NAME PHO # Elm <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE C zip '75 , <br /> 67 <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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S ATE and FEDERAL laws. -7 <br /> APPLICANT'S SIGNATU iiAf - DATE. <br /> PROPERTY I BUSINESS OWNER Lld OPERATOR I MANA OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title I <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the pwner 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 environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it Is provided to me Or <br /> my representative. PA%rim� <br /> if <br /> TYPE OF SERVICE REQUESTED: d <br /> COMMENTS: . . JUL 18 201? <br /> �1? <br /> SAN JOAQIIIN COU � <br /> ON ENT <br /> HEALTH De TMEAL <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: --7 - /8 /7 <br /> ASSIGNED TO: 'E � _ EMPLOYEE#: DATE: - , / 7 <br /> Date Service Completed (if already completed): I� SERVICE CODE: PIE: <br /> Fee Amount:' Amount Paid 15�21 OD Payment Date 7 X111 <br /> Payment Type 11 :Invoice# Check# Received By/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />