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4 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FA ILITY ID# SERVICE REQUEST# <br /> OLA+NER I OPOR _ 1 <br /> CHECK ifEILLIIdGAL,')i-_SSL <br /> FACILITYNAME <br /> SITE ADDRESS <br /> Street Number DIrrct"on <br /> DOME or MAILI"G ADDRESS (I Different from Site Address) _ E <br /> _ CLeet Numbcr ' <br /> CITY _ � - NATE QIP <br /> Pi,aNr4 EXT. APN# LAND USE APPLICATHIN# <br /> ( ) <br /> PHONE#2 — � EXT B05 GIST iICT ] I C3CATION CODE <br /> CONTR A CTOR SERVICE R-EQU STOR <br /> R,EQUESTC R <br /> 100-0x-1(— CHECK fe i3i.t UNGADDRES <br /> BUSINESS DAME :'& PHONE# ExT. <br /> HOME or IAAILING ADDRESS r FAX# <br /> CITY r+ ✓1 STaTE ZIP <br /> BILLIN{'sACKt4OVV-LE6GEMEATI: i, the undersigned property or business owner, operator or authorizedagentof 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 11 Z0 -,?o <br /> PRO?ERTYI BUSINESS OWNER❑ PERATORI MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BfLL)NG PARTY,proof ofauihorization to sign is req uiru�d rif re <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or opt rator 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 JOAWN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It is rovided to me or <br /> my representative. YMENY <br /> TYPE OF SERVICE REQUESTED: r c x RECEIVED <br /> COMMENTS: +, , NOT 2 8 20% <br /> �-PC11 SAN JOAQUIN COUNTY � <br /> ENviROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#; DATE: —.25Y <br /> r] _J� <br /> ASSIGNED TO: Lzoh/e /S� EMPLOYEE#: DATF' �l <br /> Bate Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid' Payment Date r { CP <br /> "a lam <br /> Payment Type C �C S Invoice# Check# 7 d If 1 f Od Received By: <br /> i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />