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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of <br /> Business or Property n FACILITY ID# SERVICE REEQUES # <br /> � �ctrGt - l r f <br /> snmu <br /> OWNER/OPERATOR <br /> h � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS q G 9 ( / ` � C / . q52-0-7 <br /> ( (G ✓t L ( c'sr� <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) C r_ 1 ✓ ^ <br /> L Street Number Street Name <br /> CITYI / STAT ZIP <br /> C14 '7523 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 44,4, <br /> x • CHECK if BILLING ADDRESS <br /> BUSINESS NAME1 <br /> '1 t PHONE# EXT. <br /> � r e S f 1 ?c - v-,,-HOME or MAILING ADDRESS 1 FAX# <br /> CITY STATE ZIP 195r-2()3 <br /> C; <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. <br /> APPLICANT'S SIGNATURE: A X1,4 'w DATE: <br /> PROPERTY/BUSINESS OWNER 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 assessmen/JAf ��,rm```a���tion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prOV,LOC�t �1r <br /> my representative. /�)) RR <br /> TYPE OF SERVICE REQUESTED: S ( V/J h <br /> COMMENTS: <br /> _ h�H pM����N <br /> C�VMIG 7 Q�1�J✓c.erp p� T <br /> MFHT <br /> ACCEPTED BY: EMPLOYEE#: /� DATE: <br /> ASSIGNED TO: EMPLOYEE#: UUU✓V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE:f l no/L <br /> Fee Amount I Amount P� /S��D Payment Date 3� <br /> Payment Type2�4zeA--1Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �I1VU <br />