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SAN JOAQUiry COUNTY ENVIRONMENTAL HEALTH LCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 111 r,, tf] 1�t �. ,S O]� /VC CHECK of BILLING ADDRESS <br /> FACILITY NAME ^ "� A%"J <br /> J AC�ZJI 41 <br /> SITE ADDRESS r96 ( 16 NO N WF—:s / �P1—/�J� 1 U TDC`���A� C4 �5 a 111)Street Number I Direction Street Name StU�1) I Cf Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P-9 Street Number Street Name <br /> CITY j 6 CSC._YU AJ STATE cit zip 9 ` z <br /> PHONE#'1 I EXT. APN# ��lJ/1 L LAND USE APPLICATION# J <br /> (an) -7 3-16-1 R- 0 L34 <br /> PHONE#2 EXT. BOS DISTRICT LOC ION CODE <br /> �avr ) �� ), -aSp CC, 0-, r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> V� \/\ (� v\�f\Cl - PHONE# �j 0 Exr. <br /> HOME or MAILING ADDRESS d J� FAX# <br /> S 16 CITY STATE ZIP q <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 applicaf and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 0 RATOR/M GER 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 to me Or <br /> my representative. PAYMM <br /> c <br /> TYPE OF SERVICE REQUESTED: O(x1 Cov1 L,(.I l �j� RECEIV <br /> COMMENTS: SEP'2 9 201 <br /> J <br /> SAN JOAQUIN COI INTV <br /> ENVIROMENTA <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ! /-n EMPLOYEE#: DATE: <br /> ASSIGNED TO: © G EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 to , P/E: <br /> Fee Amount: `�jC��>� Amount Paid �� Payment Date �� S <br /> Payment Type ✓ Invoice# Check# �0/c: Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />