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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G S4-v-�-C X) 6(p 5_57 <br /> OWNER/OPERATOR^ � A C t"TS C <br /> �� C CHECK If BILLING ADDRESS <br /> FACILITY NAME A (E n 6� 4—Fu V b —T <br /> SITE ADDRESS d� !� ��71�7c/-3 4� 3&4L, <br /> 3 0 E- Stree[Number Direction v✓� ` Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6 b L � Street Number Street Name <br /> CITY STATE Z I Wt( <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Sia) 3q6 55410 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> .2.gVgb M)S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ ' A <br /> N�µ �( ✓� CHECK If BILLING ADDRESS <br /> BUSINESS NAME -7 PHONE# C EXT. <br /> Sib 3 i,6 �S <br /> HOME or MAILING ADDRESS FAX# <br /> CITYn C_� n ST ,TE ZIP Q 1 33-6 <br /> Jq <br /> BILLING ACKNOWLEDGEMENT: 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 /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL S. <br /> APPLICANT'S SIGNATURE: J DATE: <br /> PROPERTY/ USINESS OWNE OPERATOR/MA AGER AUTHORIZED AGENT El <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tifle <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 ass�` I�' Ion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the Same time It I6�� g{ir <br /> my representative. E tl�1.J <br /> TYPE OF SERVICE REQUESTED: Wc 19 <br /> COMMENTS: <br /> SAN JOAQUIN COUN <br /> Ty <br /> ENVIRONMENTA T <br /> HF-ALTH DEPARTM <br /> ACCEPTED BY: � SEMPLOYEE#: S�d DATE: S I S l C <br /> ASSIGNED TO: L��UJ�CJJ//II�� EMPLOYEE#: 0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / I E: <br /> Fee Amount: Amount Paid15� Payment Date `cJ <br /> Payment Type VVI I& Invoice# G ff k# 3 3 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> ��bo l23SS <br />