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SAN JOAQaii.4 COUNTY ENVIRONMENTAL HEALTH jEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nnSERVICE REQUEST# <br /> OWNER I OPERATOR <br /> N �r CHECK If BILLING ADDRESS <br /> FACILITY NAME n l A0n <br /> AMIM <br /> SITE ADDRESS <br /> ESS irection r'0 inti G�V � rt � CiV Y l Tq;zo <br /> Street Number Deel Name Ci ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) O�� (� <br /> ( "(Il � Street Number Il/YI Street Na Ime <br /> CITY J. v / *o TAfCE ZIP 61,0 <br /> PHONE#1 EXT. APN# LANDUSE APPLICATION# <br /> +, <br /> (Zoo) 0-5g5v <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( aIk) q23-3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR DA/L Aa � X <br /> Cj J CHECK If BILLING ADDRESS <br /> BUSINESS NAMES <br /> �J��� PHO # ,I EXT. <br /> HOME or LING ADDR S 'V(T 7/I/Gjr v FAX# lU S <br /> (u � ?� Olt h ( ) <br /> CITY � �A 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, Standards, STATE and EDERAL laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1:1if APPLICAN 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 /> 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 OF SERVICE REQUESTED: "z� <br /> COMMENTS: V'gD <br /> sqN JoAY 1 ?015 <br /> fgr�AQUlty <br /> HEAi,rh OCAR 'rAI <br /> ACCEPTED BY: EMPLOYEE#: DATE: T�? <br /> ASSIGNED TO: `� �q �1� EMPLOYEE#: DATE:�� <br /> Date Service Completed (if already completed): / SERVICE CODE: / P/E: <br /> Fee Amount: / ,Uv Amount Paid �/�/) n%� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />