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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REEQQUEST# <br /> Si9S Z- �aoi� � � 00-702 i/ SP-(Y)76 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS•• <br /> FACILITY NAME <br /> C i/f�fZ/E� wl9> <br /> SITE ADDRESS SOS 7irt• /W' JF S1VD 92S,;?&, <br /> Stree[Number Direction Street Name city Zip Cod. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> z�5) Z/ef 3 '�/40 <br /> PHONE#2 - EXT. BOS DISTRICT LOCATION CODE <br /> teas ) 95'2-/�3� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�^Y'-� <br /> AV j�Dl�� .J C���X1/'1�// CHECK If BILLING ADDRESS <br /> BUSINESS NAME'\ PHONE# EXT. <br /> HOME or MAILING ADDRESS /�� �j'(J' ,�Oj,�/-ji/pG� L,j yl�/ FAX# <br /> ( ) <br /> CITY ,eO n STATEe� ZIP 5�Y3ev <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 a�oERAL IIlwS. <br /> APPLICANT'S SIGNATURr�E:: DATE: // / <br /> PROPERTY BUSINESS OWNER v 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 provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: 'LA / EMPLOYEE#: DATE: <br /> ASSIGNED TO: W EMPLOYEE#: DATE: 1011 I} <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 2— <br /> Fee Amount: `�`—' Amount Paid " Z Payment Date I 1 / I --r <br /> Payment Type Invoice# Check# c-`I- Received By: J- <br /> J �� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />