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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2D i <br /> OVVhER i CAPE TOP `J CHECKS if BILLING ADDRESS <br /> FACILITY NAM , re— 9 (� <br /> SITE ADDRESS <br /> � � } [, C93�C <br /> 3-131 C Zi Code <br /> 1 LO Street Number Direct street Nam <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY rT n <br /> STATE ZIP <br /> PHONE#� El T• APN# LAND USE APPLICATION# <br /> 0� ) y-79 <br /> PHONE#2 � , EXT. $C75 DISTRECT LOCATION COD <br /> (20) <br /> CONTRACTOR SERVICV, REQU S'P'QR _ <br /> REQUESTOR r'}- CHEC,If BILLING ADDRESS <br /> IA r-�-e,r <br /> BUSINESS NAMEh PHONE# ExT. <br /> NC 3 S0,�V\' o 15 ?- le- (:2-61) q7?- 13 8 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE�i ,ZIP /63S2!G <br /> 4 1 / <br /> BILLING ACKNOWLEDGErAENET: 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 /> J COUNTY Ordinance Codes,Standards, STATE and FEDERAL S. �j <br /> APPLICANT°S SiGNAT URE: _ DATE: 712 _ dG0/ <br /> PROPERTY 1 BUSINESS OWNER P, OPERATOR I MANAGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ti rte <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 informati n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is provided r <br /> my representative. <br />{ <br /> TYPE OF SERVICE k?EQt:ES7ED: R12 LLrO on C, 6 <br /> COMMENTS: <br /> c� <br /> 0Z-0fUA-J NsoAAQ�' <br /> N <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �j� EMPLOYEF#; DATE:—7, <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: t /D <br /> Fee Amount: 2;,0 r Amount Paid l - , + Payment Date '"7 z5 [ <br /> Payment Type I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07117/08 <br /> IG <br /> 4 <br />