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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> `. <br /> SERVICE REQUEST . <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ckt4(DA 3-707 3'1W05940 ,1- <br /> OWNE / PERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME I n M��5. SO!✓S v��! �— <br /> SITE ADDRESS jT <br /> I \JJ fL� Jt �L <br /> Ire¢ Nu�er Direction ��Q'�I Rtreet Rarhe CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCA 10 CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORt 0 I J qtAln d <br /> J �J CHECK If BILLING ADDRESS <br /> 11 <br /> BUSINESS NAMEPHONE# ExT. <br /> S- <br /> HOME or MAILING ADDRESS FAx# <br /> ( ) P �l <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of <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 app ' a n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE F D L laws. /I <br /> APPLICANT'S SIGNATURE: DATE: -S-S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT n <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is requir¢ Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. F70 O 0 ,OL,'r/ t,�{ G� �-( !•�O.C.— �6�1Ot7 E L <br /> TYPE OF SERVICE REQUESTED: — ENT <br /> COMMENTS: _ \ RECE( <br /> C � � Pi2� e�yJ MAY - 1 2010 <br /> N C car t I^ r <br /> SACOUNTY <br /> N H DEPA NT ENT <br /> P.ti`I �R �/CitF� � HEALTH DEPARTMENT <br /> ACCEPTED BY: O L t l�Et ,� ,�t 0V00""�" EMPLOYEE M C 3 2—/ DATES •7/l B <br /> ASSIGNED TO: '� /�--�-r EMPLOYEE M C)a DATE: s '] / 0 <br /> Date Service Completed (if already completed): SERVICE CODE!: Zy <br /> Fee Amount: 3 D , Amount Paid C) _ Payment Date S <br /> Payment Type Invoice# Check# ,`) Received By: !, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />