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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> 1 SRQ�}882y <br /> OWNER/OPERATORn O <br /> l//r CHECK If BILLING ADDRESS� <br /> FACILITY NAME 1he <br /> (�Rd <br /> ,rT <br /> ig- <br /> SITE ADDRESS co0ao LIv\ \�m aN� ;1 0, _ <br /> Street Number plrectlon P Street K�J ��rO CI �Z�C�� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �- <br /> r9-51 -Tra-�aQy Street Number 6treet Name <br /> CITY , STATE <br /> S <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (L?d� 3 - l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> V CHECK If BILLING ADDRESS <br /> BUSINESS NAME V r' P( NE# E'�T <br /> - �d (0 9-1 7 <br /> HOME or MAILING ADD,_);SS FAX# <br /> C25- ( ) <br /> CITY ( STATE ZIP 9 <br /> BILLING ACKNOW GEM T: 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 TE and FEDERAL laws. �y <br /> APPLICANT'S SIGNATURE: �j� DATE: 3 QI/ J <br /> PROPERTY/BUSINESS OWNERTic OPERATOR/Ni ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tine <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 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 to me or <br /> my representative. N <br /> Alex— <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Ver tae- rla� -hD S� Ccunfiv�' MAR 0 <br /> Save , ZOfB <br /> FNI0'9QUlN <br /> '/ HF'gLr/y C% �N�Y <br /> ACCEPTED BY: p.( EMPLOYEE#: DATE: <br /> ASSIGNED TO: � i EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): / SERVICE CODE: Je27� PIF: I(QDl <br /> Fee Amount: Ocso Amount Pa(ZI / b Payment Date c3 /�D <br /> o L <br /> Payment Type i � Invoice# Check# 76 3(, !ZZ ReceiLed By: <br /> 6147�- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />