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SAN JOAQUIN C 0 <br /> Q COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATO <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME It C <br /> SITE ADb S /,I6 ACJ �✓��[ ��/ �I G� �� <br /> L � W Street Numher+ Direction /` t Name ��• L�� <br /> CI <br /> FIOPr"E G'i MAILING ADDRESS (If Different from Site Address) Zi Code <br /> Street Number Street Name <br /> CITY V9 STATE ZIP - <br /> PHO'.; 'i xT APN# <br /> LAND USE APPLICATION# <br /> PHONE [" BOS DISTRICT LOCATION CODE <br /> CONTRACTOR// SER1710E REQUESTOR <br /> REQUESTOR _ <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME I <br /> C, - <br /> HOME or MA!I INr,ADDRESS <br /> CITY STAT ZIP <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned prope or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL EALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to me or my business as identified on this rm. <br /> I also certify that I have prepared jSTE <br /> atio an tha e work to be performed will be done in accordance with all SAN JOAQVIN <br /> COUNTY Ordinance Codes, Sta arda F ER laws. <br /> ArPrPLICANTTS SIGNATURE: DATE: —� <br /> PROPERTY 1 BUSINESS OWNErtAN OPERA- 1 MA ER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT r of 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 ififormation <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. <br /> TYPE OF SERVICE REQUESTED: R T <br /> COMMENTS: D <br /> C.I'la✓>cj e �� �� 2l' AUG 0 9 20 6 <br /> SAN JOAQUIN CO <br /> ENV113O84ENtq N7y <br /> HEALTH DE_pADrM NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: !ll EMPLnYER_#: DATE: <9 <br /> Date Service Completed (ifalready completed): rpv!r_L-COor:� � i Pi E: <br /> Fee Amount: i -` Amount Paid . Payment Date 19-1-711 <br /> Payment Type 1 Invoice# Check# Recei d By: <br /> EHD 48-02-025 (SR FORM G ) <br /> 07/17/08 olden Rad <br />