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; :. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l SieWS-3,35V <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 97k 5-1 5 '45 r/2 b I2414 +7 <br /> Street Number I Direction Street Name Zi Code <br /> I HOME or MAILING ADDRESS (If Different from Site Address) 3 76�f <br /> Street Number Street Name <br /> } CITY STATE n ZIP���B <br /> i Q C�J <br /> PHONE#t Exr. APN# LAND USE APPLICATION# <br /> (20P S- pZ 5-O7o A --p _r <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQU ESTOR CHECK if$ILLING ADDRESS <br /> BUSINESS NAMEPHONE# _/�o� ExT. <br /> rU E 1V Scc ✓ <br /> 1 r � <br /> HOME or MAILING ADDRESS FAX# <br /> ©� ( 1 �— <br /> CITY STATE <br /> } BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appl' ' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S T and FEDERA aw <br /> APPLICANT'S SIGNATURE: DATE: �r D <br /> PROPERTY/BUSINESS 0R9NER❑ OPERATOR/M AGER"Er OTHE UTHORIZED AGENT <br /> ifAPPLicANT is not the BILLING PARTY,proof of authoriza ton to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> } T <br /> TYPE OF SERVICE REQUESTED: 5�'l2- rU$ G„17- CV/5 Al ECEIVEM <br /> COMMENTS: SEP - 9 2008 <br /> L(�(dff <br /> 'SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEAL?H OEPARTMEN-r <br /> 'I ACCEPTED BY: { J L EMPLOYEE#: 02,? DATE: C <br /> ASSIGNED TO: L O-PO U-L©S EMPLOYEE#: ('}t)(,S DATE: c� Cr (j g' <br /> Date Service Completed (if already completed): SERVICE CODE: 5�2-2, PI E:o2&DI <br /> Fee Amount: p�j Amount Paid 6b Payment Date l 6 F, <br /> Payment Type Invoice# Check# Received By: <br /> w <br /> EI-iD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />