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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> �C-Y-NiLkAo--'T -- F�A'CG0ZZ�3 Sr2oo7L <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME C <br /> cyt <br /> SITE ADDRES_ S `+�L (tel C ���C�U T J ZG <br /> �,4HVs�,G_Street Number Direction Street ame Citv Zio Code <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 /> PHONE#2 EXT* BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE I RQ C / 6-7 `,�M) ` 1LU 04` CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# ExT. <br /> xG <br /> HOME or MAILING ADDf;ESS FAX# <br /> CITY `��C (G � STATE ZIP h-2-0 <br /> 7 <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 /> 1 also certify that I have prepared this appli i n nd at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST ED RAL laws. �/J APPLICANT'S SIGNATUR ' DAIE: 7 ,3 G <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> I(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 provid tQ#qe or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �� <br /> COMMENTS: At <br /> JUL c <br /> �,a�.►ts1 COU <br /> SA k ►RU�PAHtM NT <br /> NE.AL1 H <br /> ACCEPTED BY: EMPLOYEE#: DATE: r5 <br /> ASSIGNED TO: I 1',4` o EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �V I P/E: (p pZ <br /> Fee Amount: C) c Amount Paid Payment Date <br /> Payment Type Invoice# Check# ! —y ! Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />