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09/26/2008 FRI 16:49 FAX 2094583433 SJC EHD 0007/007 <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY <br />SERVICE RE UEST # <br />OWNER / OPE OR <br />n <br />f <br />ACCEPTED BY: 4 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: &e✓ <br />EMPLOYEE #: <br />SITE ADT <br />Ss <br />et Number <br />on <br />SERVICE CODE: <br />tr <br />Fee Amount: _ <br />Amount PaidPayment <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />invoice # <br />Street Name <br />CITY <br />STATE zip <br />PyQwfi #]„ �. � T �^ ,., EXT. <br />J� �Jc,, c)— ll�it/ J`�E[xr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #22 <br />( l <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />02 <br />STATE <br />CHECK if BILLING ADDRESS El <br />r I n n EXT. <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL, HI i.,ni DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my b as identified Or this folio. <br />I also certify that I have prepare is application an th work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, St OVA AL awS. \ <br />APPLICANT'S SIGNAT nTk: 1 � =-Q <br />I'ROPP.R'I'Y/I3USINF.SSOwNFR OPER\TOR/i ANAGER OTHFmAu,rnOI1IZ£DAGI:N" <br />I f APPI ICAM' iS no! the 1311 /.L ARTY proof t�f authorization to sigfr is requir ! Title <br />AUTHORIZATION TO RELEASE INFORNIATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL. HEAL'I'LI DEPARTMEN'r as soon as it is available and at the same time it is <br />provided to me or my representative. —.,,h n e NIT <br />TYPE OF SERVICE REQUESTED: <br />—. <br />IV ED <br />COMMENTS: <br />Nov 2 4 2008 <br />SAN JOAOUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 4 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: &e✓ <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: _ <br />Amount PaidPayment <br />Date \` 2y O <br />Payment Type �� <br />invoice # <br />Check # 2 91. d <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />