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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS D <br />EF' <br />FACILITY ID # <br />PHONE # EXT. <br />SERVICE REQUEST #C' <br />r� P <br />HOME or MAILING ADDRESS <br />FAX # <br />7 u <br />(S <br />OWNER kQPERATOR <br />11 <br />rr E <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />G + <br />wL <br />SITE ADDRESS <br />ACCEPTED BY: <br />Nk f -Pam JA,VE <br />1 ODr <br />L. <br />(15.24/ <br />Street Number <br />Direction <br />Street Name <br />c1tv <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Z. <br />Street Number <br />Fee Amount: <br />Street Name <br />CITY <br />Payment Date <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />Received By: <br />_ <br />0 �2 <br />PHONE #2 <br />EXT. <br />BCS DISTRICT <br />LOCATION." D <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS D <br />EF' <br />BUSINESS NAME t <br />PHONE # EXT. <br />� �n <br />" <br />- / �� <br />HOME or MAILING ADDRESS <br />FAX # <br />7 u <br />( ) <br />CITY l.(Z STATE co ZIP (25-311, <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, p�!, <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 JO <br />COUNTY Ordinance Codes, Standard , STATE F DE laws. ✓ �,Y�` <br />APPLICANT'S SIGNATURE: 7����^ DATE: SqN UN 0 $� l�O <br />PROPERTY / BUSINESS OWNER ❑ iii& II MA AGEP,2 - OTHER AUTHORIZED AGENT ❑ yF NV/ q�// !s <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title OFA Fti 0 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the abo -. <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information Nj. <br />to 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: /n <br />V/ <br />ASSIGNED TO: <br />/ _ O <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Z. <br />PIE: aU <br />Fee Amount: <br />i <br />Amount P �� Uv <br />71 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 10-7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />