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SAN.JOAGUTITCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bus' ess or Property FACILITY ID# SERVICE REQUEST# <br /> a#Ao ,�ooaa7ofl � -71 `l�5 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 5 <br /> FACILITY NAME C <br /> SITE ADDRESS1l 1 t D <br /> 1 Street Number Direction tTreTet Name)/\� �^ Zip Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Ad reSS)• <br /> �� S t1LRiee[Nul ber street Name <br /> CITY O STATE ZIP <br /> Cat <br /> PHONE#11` Ex . APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> IO W (2c Y14 RU �10 to 16 A4 I 1- <br /> HOME or MAILING A # <br /> DDRESSS� 1 FA% <br /> A '••GWS_ .11 (011(a) 3 7 <br /> CITY 1.11 e ^ d $TATE ZIP O <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 ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATE and FED AL &I <br /> APPLICANT'S SIGNATURE*x DATE: O <br /> PROPERTY/BUSINESS OWNER❑ / -OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EJ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sigh is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above y <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 a5 It IS available and at the Same time It Is provided t0 me or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: /�,. ECE <br /> COMMENTS: 4i7—'[--AS� Q I` G A G Nf C x P10 R <br /> �y Y 101 <br /> �• �'t '4"JOAQUIfy <br /> HEq TVt ME)y O TV <br /> 7 H pEpA <br /> ACCEPTED Y: EMPLOYEE#: DATE: f/ <br /> ASSIGNED TO: EMPLOYEE#: /1j DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: J <br /> Fee Amount: 3� O 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 />