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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 510 <br /> S�00 r <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> T oGEr-5 GE <br /> SITE ADDRESS /a-9.2-7 N/ /?,/ <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4/,.2 S wE5r <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> AlPoN Gtr S' <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> V ) 2Ye e -0653 8-(70-0 <br /> PHONE#2 EXT. BOS DISTRICT 7LOCATION CO E <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Do N CHECK if BILLING ADDRESS E] <br /> C HESIvE E <br /> BUSINESS NAME PHONE# EXT. <br /> oz-/ -5-p- <br /> HOME or MAILING ADDRESS FAX# <br /> 0 ( ) <br /> CITY Tu RLD STATE ZIP 2 / <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 appli Getion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA ndFECEPA laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment inform <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time It IS provided t0 0 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> So/c oici7 i o r F✓/jFwlF o <br /> COMMENTS: ,/Oq <br /> p1,9 <br /> Fp FN �N <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P'5: b <br /> Fee Amount: b Amount Paid7p4a6b Payment Date <br /> Payment Type Invoice# Check# Z3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />