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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR <br /> de-Z-- CHECK if BILLING ADDRESS <br /> FAciuTYNAME <br /> SITE ADDRESS CA <br /> Street Nu bar Drs tI fres Nanm city <br /> <br /> <br /> CITYSTA zip <br /> c' , <br /> PHONE#1 , T APN# LAND USE APPLICATION# <br /> (t'n) ��,, -- 3(pig <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( } o U L4 Cl) <br /> CONTRACTOR 1 SERVICE REQIUESTOR <br /> REQUESTOR r t 1 GI1 IC( L CHECK if BILLING ADDRES <br /> J-✓i <br /> BUSINESS NAME PH9NE#_ L Bxr, <br /> If �L'1 F ( wl G `jam Lr r �tp O <br /> HOME.Or MAILING ADDRESS FAX# <br /> CITYSTATE �, ZIP <br /> L, 10f <br /> BILLING ACKNOWLEDG MENT: 1, 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,STAT4 and FED . laws. <br /> APPLICANT`S SIGNATURE: DATE: <br /> PROPERTY i BUSINESS OWNER OP TO /MANAGER E3OTHER AUTHORIZED AGENT C3 <br /> If APPLICANT is not the BrLLM PARTY;proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assessorormation <br /> to the SAN JoAOUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It i5 pr�ll <br /> my representative. <br /> c,mLt. <br /> TYPE OF SERVICE REQUESTED: C SAdA I, <br /> CiOMMENrs: SAN. 1.11 6 ?01 <br /> 1/04 <br /> 1R ROMtitCO <br /> UN <br /> H 0 -rAt <br /> ACCEPTED BY: ��c` EMPLOYEE DATE: <br /> ASSIGNED TO: 5'��1�� EMPLOYEE# DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Pf E: 7J <br /> Fee Amount: Amqunt Paid lS� b-D Payment Date <br /> Payment Type Invoice# Ch It# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />