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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z- Skol)�(V,-2,5 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> IWI? . 5.6T E T <br /> FACILITY NAME <br /> AF,47-PI,91-6 PESlGE <br /> SITE ADDRESS t2- w 2�t70/�/ ,QD /i�O� gS3GG <br /> Street Number I Direction Street Name city'/ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) L S k/tESr 80�SerI vim' <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> R!po i�-7A S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 4* ) -0653 X29-(70-0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Do N C H�Sn/E E <br /> BUSINESS NAME PHONE# EXT. <br /> c <br /> HOME or MAILING ADDRESS FAX# <br /> t7 94 ( ) <br /> CITY TU RLo STATE ZIP 5;� / <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 /> also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA nd.FEDERA,laws, <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT 19/ <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 /> 10 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: (3/ 17 IAI 772 O T F✓/E `® <br /> COMMENTS: %/Oq <br /> yT�i�po oif, �J.9 <br /> y�F-9,QFT �N�Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P'5: <br /> b <br /> Fee Amount: b Amount Pai � �� Payment Date ? () <br /> Payment Type (P Invoice# Check# �3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />