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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - �10(o�'� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction �u��''r�'Bt Name ZI C�J <br /> HOME Or MAILING ADDRESS (If Different fr m Site Address) <br /> 2 Z� S�A7 -,�e / <br /> Street Number Street Name <br /> CITY �Ae2 , � STATE zip <br /> PHONE W EXT APN# LAND USE APPLICATION# <br /> 2S/_ 7714 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> G, CHECK If BILLING ADDRESS <br /> BUSINESS NAMEI� PH n# EXT. <br /> 251- 2- <br /> HOME <br /> HOME Or MAILING ADDRESS -2-^ 3 f Parr/ FAX# <br /> L X11- r ( ) <br /> CITY STATE ZIP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FE laws <br /> APPLICANT'S SIGNATURE:: DATE; El <br /> PROPERTY I BUSINESS OWNER 12 OPERATOAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PART 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provldep e Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: :DWC �1 <br /> COMMENTS: <br /> °' Q�0 <br /> 3 � 9 <br /> TyOFpgRNOU ry <br /> SEN <br /> ACCEPTED BY: / , EMPLOYEE#: j/) DATE: / 3 <br /> ASSIGNED TO: 1 EMPLOYEE#: �(2 Sv l/ DATE: 11310 <br /> I 3 /9 <br /> Date Service Completed (if already completed)-' SERVICE CODE: i1 PIE: (p CL <br /> Fee Amount: �' uj Amount Pail5 Payment Date 3 <br /> Payment Typed_ Invoice# Check# Rec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ����� (f <br />