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DATE: <br />OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />F <br />ijrpe of Business or Property <br />fe; rekl 53/-L? / ?-e- 5 <br />FACILITY ID # SERVICE REQUEST # <br />gQ ajzOq 1(40 <br />OWNER TPERATOR A <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />42 // 0 E ....),,,,tic,,,.--/ 4-.1 Street Number Street Name <br />CITY <br />ArGi frAiorn <br />6.._SWE ZIP <br />.7 5.1A9 <br />PHONE #1 <br />92) 79?- c(e /7 <br />EXT. APN# <br />007" 2612?) - <br />LAND USE APPLICATION # , <br />M -/ P-60(156 , p-ed a Ft; <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT ii, LOCATION CODE aa <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br /><'71/11 C C-7 1- A 12G,t7f <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT <br />HOME or MAILING ADDRESS Fax # <br />( ) <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 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, Standar s, STATE an •ERALAit <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGE <br />If APPLICANT is not the BILLING PARTY pr f 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 information <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 SERVICE REQUESTED: 2i1 /f101Palliiiikieet./67 OF .,-)fi ,---/DA,9//J ' <br />COMMENTS: <br />RECE/ VED <br />2 1 201,9 SAN ja,AQ <br />Eivviao l-EN couN kisuril t,g,,mAPNTAL T ,' <br />ACCEPTED BY: 4 EMPLOYEE #: ---'-liRritnEA1 DATE: 41 ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/E:41/6d I.,- <br />Fee Amount: Amount Palo:0 60X17:) Payment Dat <br />44/r <br />Payment Type Invoice # Check # ll)62,._ Recei ed By:y/er <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)