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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE'Q'UEST# <br /> ��gfi ,S�2oo-7�FG <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 3z�aL3 <br /> Street Number DlrecHon 'idl HIM2CI l i Cotle <br /> HOME 0/dAILI ADDRESS (If Different from Site Ad/dress) <br /> t. Stn t Numtwr Street Name <br /> CITY \ � S� ATE zip C—` I C 3 . ..._ <br /> PHONE#t En' APN# LAND USE APPLICATION# <br /> ( )St0 4 CoZ-y\ C 1 <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR RVICE REQUESTOR <br /> REQUESTOR LA CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE En' <br /> HOME CrMA ADDRESS FAX# <br /> CITY 1 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 /> 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 an ED RAL la <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 Titre <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 infonnatio/r�� <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me <br /> my representative. y�, <br /> TYPE OF SERVICE REQUESTED: � Pla-r — (,/.. (La( <br /> COMMENTS: F �\E,o voc \\c IAJ O'Jff\YJve-re—, tc\ 1 Sf�Lt�(T_ 11 fY ,z <br /> Fq<ryo p CO <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I 1 <br /> ASSIGNED TO: ( ' / ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: IW <br /> Fee Amount: CJ30 Amount PAI4 `� �'i;•, , Payment Date <br /> PaymentType Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />