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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#--L /[ <br /> F/� 6cow s <br /> OWNER/OPERATOR F�brle WO Q <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> 0? 70, PP y <br /> S T ADD t <br /> Number `Dire tion � ame O C�oay <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 � � EXT. A PN# � � LAND USE APPLICATION# <br /> V/1ip i -�j <br /> PHONE#2 EXT. / BOS DISTRIC00 T LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORSIN SS NA0 L� <br /> -1 l �j CHECK If BILLING ADDRESS <br /> BUME_ ���` PG" ' �p j 01 rxT. <br /> HO E or MAILIN D ESS ` FAX# D I �/1 <br /> CITY �G �« 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 agp'cation and that the to be q formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards ATE and FEDERAL I S. /J <br /> APPLICANT'S SIGNATURE. <br /> 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 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 assessn i formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS V or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �✓o <br /> ?0�8 <br /> H�NVjRQ /IV CVN <br /> � d Con s � i ��n�-s �.> Pa c�� �( •n.e-�- "o�p,�M NT <br /> p G O FFP ow //r�f✓ Lv n-1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �. C J �.} Z_ EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Y P/E: U <br /> Fee Amount: Amount Paqf ) Payment Date G <br /> Payment Type C Invoice# Check# S Recei ed liy:al <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />