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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 665 <br /> OWNER/OPERATOR <br /> 1�0 lee- + CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 3 CC) /0f � �� ►\ t �d� �/5 2(6 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street N me <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME1 PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> -3619 �Ivl b C •f ( ) <br /> CITY /� } �C STATE C a ZIP Y5-0 <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. <br /> 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: <br /> z < u DATE Z�'' /'y. <br /> PROPERTY I BUSINESS OWNER❑' OPERATOR/MANAGER ❑ OTH R AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A �e c- !</ <br /> Se/ _17tt4-4-4 <br /> y <br /> 13 /C) EU2 4-4✓//4 re- +I���cl CA.— <br /> ,,OA <br /> ..,_ c����u,��✓ /1 /Z c �: ZO_/� <br /> Cnt � IMec44c1 ce-e rel w r^a'e.4lr � r— <br /> / 11 // �.. <br /> (r Ln s e'c 'i' J Te<e I\�L/1I� '70 SU�,ti.r ,/r�:.�t� t 5�+�lC "�2�ese ✓� ,/�4i/� <br /> Gve�e ;�CUA t- e v� 6 � / 5 J C /> <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />