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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ EST N <br /> 001 om-0 <br /> OWNER I OPERATOR <br /> C N CHECK If BILLING ADDRESS <br /> hA <br /> FACILITY NAME <br /> 114 <br /> SITE ADDRESS G= j <br /> ry <br /> �S c' Street Number Dlrec ion " Street Name) city Zip Code <br /> HOME or MAILING ADDRESS (if/Different from Site Address) f I /J <br /> C.$ — l(\ T/ I A ;ss ( I 45.t Number /7 Street Name <br /> CITY STATE ZIP <br /> '-G\' <br /> PHONE ill EXT. APN# D MND USE APPLFATION# <br /> PA <br /> PHONE## EXT. BOS DISTRICT / LOCATION CO <br /> 11 "t <br /> �. CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> PZ <br /> C M(3f,,y ' CHECK If BILLING ADDRESS <br /> t `1 BUSINESS NAME) — /` PHONE# EIT' <br /> HOME or MAILING ADDRESS FAx R <br /> 1 iVl/��✓C?G G L 4 L.-,/ ox) SSS -c, 7d'' <br /> CITY CeSTATE 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 /> 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 TATE and FED L laws. <br /> `? APPLICANT'S SIGNATURE: `1 DATE: 12 <br /> v PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT r( " Y-et��f U r <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 information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It IS provided(�me or <br /> my representative. �711, <br /> ` TYPE OF SERVICE REQUESTED: / I �'yl C j II� ' �N�` <br /> COMMENTS: +-CC f r ef4 <br /> (C/ �O <br /> �� C. > I <br /> ryo sz p�R�F ry <br /> ACCEPTED BY: EMPLOYEE#: U✓� DATE: Z ' t I� <br /> ASSIGNED TO: EMPLOYEE#: ! DATE: <br /> r Date Service Completed (if already Completed): SERVICE CODE: O PI E: <br /> Fee Amount: . Z Amount Pai �.ab Payment Date f �� <br /> Payment TypeL� Invoice# Ch k# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />