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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH AEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cs-IQ3 2 32- cSL. 6l/ <br /> OVV /OPERATO <br /> CHECK H BILLING ADDRESS <br /> FACILITY NAME t <br /> SITE ADDRESS S/� <br /> Street Number Dredion f/Zreet Name <br /> Hofl&pr MAILING AD S (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �TA ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( � - 232-2 'Fo_66 <br /> PHONE#2 EXT. BOS DISTRIC5- LOCATION CODE <br /> 7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> O CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH / Ex <br /> 3212 <br /> HOME AILING DRESS ' FAX# <br /> CITY �ad 614 STATE ZIP <br /> BILLING AC OWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my busines as identified 0' this form. <br /> I also certify that I have prepared this ap I tion and at th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T TE and F ERA aws. <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER 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, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: F-v ZlJ F-4-c f u i ( PL4,e-J G f{f- C(C- <br /> COMMENTS: RECEIVED <br /> JUN 19 2009 <br /> SAN,JOAOUIN COUNN <br /> ENVIRDEPMAER AL <br /> APAI ENT <br /> ACCEPTED BY: 0 Lk UF-L e A EMPLOYEE#: 0 3'Z/ DATE: ,? <br /> 40 <br /> ASSIGNED TO: 6 u EMPLOYEE#: DATE: Lf L?` 0 <br /> Date Service Completed (if already completed): SERVICE CODE: --5---5-Z9' PIE: <br /> Fee Amount:# &1 S Amount Paid _ Payment Date �0 ! Q <br /> ti <br /> Payment Type Invoice# Check# .. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />