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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I a W V0-- if b lo Z <br /> OWNER/OPERATOR <br /> NIMC)nn <br /> f T (son CHECK If BILLING ADDRESS El <br /> �Iin, <br /> FACILITY NAME I' ``�/ <br /> get -1W <br /> SITE ADDRESS �"/� 1 -1 � <br /> Wddr Number Direction "• �� et�/flame ���City �ip Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> L} lStreet dumber Street Name <br /> CITY STATE C A ZIP ^�� <br /> PHONE#7 ExT• APN# LAND USE APPLICATION# t, <br /> ov 5- <br /> PHONE#2 EXT. B05 DISTRICT FLDCtATION C.pDE <br /> CONTRACTOR/ SERVICE REQUEST®R <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> also certify that I have prepared IN lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar s, STA E and FEDERAL I ws. <br /> APPLICANT'S SIGNATURE: (—A" DATE: <br /> PROPERTY I BUSINESS OWNER Ltd OPERATOR I MANAGE ❑ 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 as information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time ' � or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: r:Izod /t/ 1 <br /> COMMENTS: OAIV JO <br /> Ov vif, /A/CO <br /> j"WN S W NFALTII E AF, T1' <br /> T <br /> ACCEPTED BY: �/I.p�Q�J�/� _ EtAPLOYEE I$: DATE: <br /> ASSIGNED TO: { Ir d/ EMPLOYEE#r: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 06 i PI E: /Q-Z- <br /> Fee <br /> L <br /> Fee Amount: +3e Amount Pai 3n.e) r Payment Date - U <br /> Payment Type Invoice# Check �. S Received By: - - <br /> EHn 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />