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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> hype of Business or Property FACILITY ID#• SERVICE REQUEST# <br /> OWNER/OPERP611 <br /> f CHECK If 81LLIN0 ADDRESS 0 <br /> FACILITY NAME' <br /> v _ l , <br /> SITE ADDRESS �r u� �j�dGC. l y'CCG C ?S3;7 <br /> tC� <br /> qdo <br /> �. Street Number pirection Street Name I C <br /> HOME or MAILING ADDRES (If Differe t from Site Address) <br /> Y' Street Number Street Nam <br /> CITY STATE ZEP <br /> �5 <br /> PHONE#1 Exr. APN# .LAND YSE APPLICATION# <br /> PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> { ) ©lJ <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQLIESTOR y CHECK if BILLINGADDREss ` <br /> BUSINESS NAME PHONE ExT <br /> �'� - 7�7 F <br /> HOME or MAILING ADDRES FAX# t <br /> CITY STATE zip <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 forma <br /> 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 /> CouNrY Ordinance Codes, Standards, STAT a d FEDERAL , WS. <br /> -APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR'/MANAGER ❑ OTHER AUTHOR12ED AGENT t <br /> If APPLICANT is not the BlLLlNG PARTY,proof of authorization to sign is required 1 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 CioLINTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided tWne Or <br /> my representative. 'JA <br /> �qovl MELc <br /> TYPE OF SERVICE REQUESTED: /E. / /). �/ <br /> ZAIr <br /> COMMENTS: /�r�Jgl/' I��GI�YfGJ��C l✓1 ��'� /I�r �N� /I�� ISL"/,QQ i 1 5 20, <br /> H EIy�ADUijy <br /> �4�Th RO qR qC NTY <br /> FNr <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: 1 `�� l r ' EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ;Leo <br /> Fee Amount: :590Amount P!. <br /> 470, U Payment Elate <br /> Payment Type Invoice# Check# lap Rec ved By: <br /> EHD 48-02-025 5R FORM(Golden Rod) <br /> 07/17/08 <br />� u� <br />