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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C-,a R OOCx> i S/� ov-()0 <br /> OWNER/OPERATOR <br /> R 1n U f j I - I-Wln6o CHECK If BILLING ADDRESS <br /> FACILITY NAME /_� J lam'1 a C 0r <br /> SITE ADDRESS lGrn i f' L l�� cr1�O <br /> 4 1 V Street Number Direction Street Name l�1 1 Cli _ZZii,JCode <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY �G 1'M"z STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (M) (o 41 -$Z--� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t2W1) 32I - 4 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR sop11, D <br /> V� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 andFEDERALlaws. <br /> APPLICANT'S SIGNATURE: y ( DATE: <br /> PROPERTY f BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1:1If 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 /> 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. �'\ <br /> TYPE OF SERVICE REQUESTED: C 'S �(nr u 1 tGhV 11 v�O <br /> COMMENTS: 1 0 (54� Jt <br /> 'j' <br /> PR()51�I 1001- �°�N� <br /> SP�NVPROPP <br /> �JN <br /> ACCEPTED BY: EMPLOYEE#: DATE: V1 C/161 <br /> ASSIGNED TO: 1 tNEMPLOYEE#: DATE: 1/1 p/161 <br /> Date Service Completed (if already completed): `Ierl SERVICE CODE: O& I+ P I E: �C1 7 <br /> Fee Amount: �SZ Amount Paid �2 �D Payment Date I l� <br /> Payment Type Invoice# Check# toss Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />