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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :5(Zoo .5 4535 <br /> 1! OWNERI PERATOR _ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME (� 1, J� <br /> SITE ADDRESS 5 13�u �T �� 1/� /� 1(-7�/� <br /> Street Number Direction Street Name ' Cr1 ` r`�' ' Ci Zip Code <br /> HOME Or MAILIN ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY (� 14A STATE ZIP <br /> PHONE 1 EXT- APN# / LAND USE APPLICATION# f <br /> - l $ Dol --ao-o3 0 {P� - Crc 001 <br /> /►, PHONE Ext. BOS DISTRICT LOCAT I*0 E <br /> /dii'11 ( ) <br /> CONTRACTOR/ SERVICE REQUESTO <br /> REQUSTOR <br /> 0 W ok\1%CL CHECK if BILLING ADDRESS <br /> BUSINESS NAME - ` PHONE# ' <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 Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project OI <br /> activity will be billed to me or my business as identifi this form. <br /> I also certify that I have prepared this applicafr work to be perfon wile in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA ED aws. /7 <br /> APPLICANT'S SIGNATURE: DATyyyE::�yy / I <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ AUTHORIZED AGENT¢Y <br /> If APPLICANT is not the BILL/NG 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 U (t_ SLC-i T-'+ C- <br /> COMMENTS: <br /> JUL 15 2008 <br /> Q�'�AQUINO <br /> HEALTH ENTAL n <br /> ACCEPTED BY: ©L(Lj Ft r4_./k EMPLOYEE#: _I '3 2_ A •NT-7 <br /> ASSIGNED TO: "( EMPLOYEE M ;3�P DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S Z-L P i E: <br /> Fee Amount: AI•� Amount Paid 1 Payment Date ✓) l S g <br /> i <br /> Payment Type ✓ Invoice# Check# Z 1 Received By: Nr`tl <br /> EHD 48-02-025 (Gold€n Rod) ' <br /> REVISED 11/17/2003 <br />