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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �4-`4 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> �"�S� ��2►�-�v �1 p SCS►'1� <br /> FACILITY NAME LA <br /> e`-j 'r, l•t !/,` <br /> SITE ADDRESS <br /> Street Number Direction — ` Street Name _ - - Ci Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) &.09 C ha ^ ` A vf�� <br /> Street Number Street Name V <br /> CITY M n,t`n fCi; STATE ZIP q': � <br /> PHONE#1 1 , `i V ` \ EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DI R <br /> � PATION CODE <br /> o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 0^" aO W �o-5 C�,►^ C) CHECK if BILLING ADDRESS <br /> BUSINESS NAME J�--/wJ`/ , `_ GL ` 1 PHONE G —�� xT. <br /> HOME or MAILING ADDRESS FAX# <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 FEDERAL IaWS. <br /> APPLICANT'S SIGNATURE: DATE: A- <br /> PROPERTY I BUSINESS OWNERXJ 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, 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 pwvided to me or <br /> my representative. <br /> TYPE OF SERVICE REQ�UEpSTED: �` GC <br /> COMMENTS: �1 „ r O, ),/1/�, 1 ^ Dct <br /> RO UIN CO(1 <br /> EACtHO�PM����1Y <br /> ACCEPTED BY: m ooze n j 1 EMPLOYEE#: DATE: l O+ JI <br /> ASSIGNED TO: l p�yl�• EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): J SERVICE CODE: ' IIPIIIEE: i <br /> Fee Amount: '4 ' 5Z oo Amount Pai /V,' Payment Date ld Irl <br /> Payment Type �i� Invoice# Check# 22SD Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />