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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2e 22 `� �� J I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> tA <br /> FACILITY NAME K <br /> SITE ADDRESS 2_5,-,A?>2 S c\-\\J� .\-Q, 0, C c' S 3•-7-7 <br /> Street Number Direction Street Name \ Ci Zip Code <br /> HOME or MAILIN DDRR9ES�SS (if Different from Site Address) <br /> V..7J/,�/��I l/ Street Number Street Name <br /> CITY �-�i, STATE � Zip <br /> � <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> r � � � <br /> PHONE#2 EXT. _ BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / QQ <br /> file- <br /> f 1 n CHECK If BILLING ADDRESS <br /> BUSINESS NAME 2/ 4 S 7L� / I� `S A 1 �I fe v (O TY64 C� PHONE# -2O 6 EXT. <br /> HOME Or MAILING D RESSCj �r �'V 1i2�y 'CkY1 k (AX# ) <br /> CITY ' STATE e ZIP (q S �— <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 thisapplicat' a that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STAT and F L laws. <br /> APPLICANT'S SIGNATURE.— ` ! f C� /y��L C� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: SANC�PfI i^Q <br /> FN°qQv/ <br /> HE,qjTH ONMEN Uly�, <br /> ACCEPTED BY: M EMPLOYEE#: 63 DATE: L <br /> ASSIGNED TO: O� EMPLOYEE#: P! DATE: J/' <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: )& PIE: ' V <br /> Fee Amount: \ S Z— Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> r <br />