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SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R S Eeeo'7D// z� <br /> OWNER/OPERATOR <br /> YVNM 1 ; 2-- ( O1,\1 CHECK If BILLING ADDRES <br /> FACILITY NAME 0` l41 G6D 0 GJ k- MA <br /> SITE ADDRESS �� � <br /> '7ti I 'c xStreet Number I Direction Street Name �� I <br /> HOME or MAILING ADDRESS (if gi erent from Site Ac( e s <br /> (� Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# EaT• <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE zip <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 /> 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 F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY Proof of authorization f0 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 /> 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. T ,y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> JUL 21 2014 <br /> SANENVIAQUIN ROMENTOAL n <br /> pRTMEW <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �lry /,J EMPLOYEE DATE: <br /> Date Service Completed- (if already completed): :fl8D SERVICE CODE: P PIE:�'�� <br /> Fee Amount: Lt! Amount Ap- mount Paid Payment Date a` <br /> Payment Type Invoice# Check# A ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />