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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�oDLAU3000 <br /> OWNER I OPFRA�?R -e /�(� / S CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE(ADDRESS [' 1(C / SS /yJ,`r Z <br /> ` Street Number =D1,. 11.n � Q r 1St eet Name �Sfu��� L Z' �ppe b <br /> HOME or MAILING ADDRESS (If Different from Site Address) z2re,,, <br /> 2 7—hr Street Number Street Name <br /> �-^ sT T Z <br /> CITY zip q <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2EXT• BOS DISTRICT LOCATION CODE <br /> (204 i- 41112 G1 5��-�- <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR / / f� <br /> i v ( CHECK if BILLING ADDRESS <br /> BUSINESS NAME /' �f /�4 PHONE# EXT. <br /> HOME or MAILING ADDRESS L FAx# <br /> 22 �/ di-e Ae ( ) <br /> CITY (rte /of /[ STATE Clf ZIP S-3 <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 form. <br /> also certify that I have prepared this apATE ion and work to be performed will be done in accordance with all SAN JOAQUIN <br /> II COUNTY Ordinance Codes, Standards, d F ERA I <br /> APPLICANT'S SIGNATURE- DATE: <br /> PROPERTY I BUSINESS OWNE OPERATOR/MANAGER © OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLWG 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 environmentallsite 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. PAYMENT <br /> iI TYPE OF SERVICE REQUESTED: Mop RECEIVED <br /> i <br /> COMMENTS: Wk) A t6 0 3 9017 <br /> SAN 00AOUIN COUNTY <br /> RONMENTAL <br /> KI:,EAL�V DEPARTMENT, <br /> i <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 E: <br /> Fee Amount: Amount Paid E Payment Date io <br /> Payment Type C ct Invoice# Check# Received By: <br /> 1=HD 48-02-025 SR FORM(Gol od) <br /> 07/17/08 <br />