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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> k r' ' o In SRo -71 µZs <br /> OWNER/OPERATOR CHECK if BILLING AODRESSE' <br /> Q <br /> FACILITY NAME 2 <br /> SITE ADDRESS <br /> 110 Street Number Oirecfon I" - Street Name ciN Zio cone <br /> HnOJM/ILI_NGADDRESS (If Di Brent from Site Address <br /> ((pp B �f.h Street Number Street Name <br /> CITY��. � S ATE zip <br /> S713 <br /> PHONE#1 Ext. APN# LAND USE APPLICATION#/ <br /> (7,M) aS9--791 ) Z( (S <br /> PHONE#2 ExT SOS <br /> ''DISTRICT LOC TION ODE <br /> 0V <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 laws. / t— <br /> APPLICANT'S SIGNATURE: DATE: f Z 7 <br /> .PROPERTY/BUSINESS OWNER 0-/ OPE TO 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provided te Or <br /> my representative. Mg Yiely <br /> TYPE OF SERVICE REQUESTED: <br /> VFD <br /> COMMENTS: Nl <br /> QSgly jO0�� <br /> A <br /> HE� UN <br /> yH13 <br /> I <br /> ACCEPTED BY: Gt-� EMPLOYEE#: DATE: <br /> ASSIGNED TO: U d�Q EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ) PIE: t6oZ <br /> Fee Amount: ( � Amount Pair IW,,, Payment Date 1 �� <br /> Payment Type ,i'-.-_,'. .: Invoice# Check# Rec ved By: <br /> EHD 48-02-02.5 SR FORM (Golden Rod) <br /> 07/17/08 <br />