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SAN JOAQUIN -76UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# TSE)R�XE REQUEST# <br /> S <br /> OWNER/OPERATOR . /o C:f _ CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ) 1 / } Pu '/ I <br /> � - (�On - ,E`Lt Y�J <br /> Lik <br /> SHE Al1ggESsa Street Number Direction I/�0'l ✓✓� Street ame 11�c)(�- C 'J Ooee <br /> HOME or FAAAtLIN ADDRESS (If Different from Site Address) /1 „ Q <br /> 1 0 Street Number ,(-- AM L� <br /> Street Nama <br /> CITY (J (tn A- STATE � ®ZIP 0-6 <br /> PHONE#1 I'� f\/ ExT. APN# LAND USE PLICATION# ` <br /> 0,2 5 -- 4tlL / 03 - ( ?0 , �3 //A — o7C)C, (f <br /> PHONE#2 Exr. BOS DISTRICT LOCAJr CQOE <br /> I ) 7 `!' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Me and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 aw <br /> / <br /> /APPLICANT'S SIGNATURE: '5q� Gam_ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT❑ tti <br /> If APPLICANT is not 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 <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 /> TYPE OF SERVICE REQUESTED: S'011-( 0 <br /> COMMENTS: q y^Q <br /> 3/Ta�oB C lro w.n� Sq FEB 1 5 2008 <br /> / E JDgOUI <br /> ACCEPTED BY: OC_r UcC to EMPLOYEE#: <br /> ASSIGNED TO: MGGi.E,c.�o� <br /> EMPLOYEE#: 3c? 73 DATE: ( d'c-1 <br /> Date Service Completed (B already Completed): SERVICE CODE: .Z P/E: tFp L <br /> Fee Amount: C? Amount Paid C� I Payment Date -.. 5 G <br /> Payment Type �. Invoice# Checks## c` Received By: C' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />