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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> —a__Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPE TOR fa <br /> 1 U OI^- <br /> f U, CHECK If BILLING ADDRESS <br /> FACILITY NA2StreetN..ber <br /> �i C <br /> l�W <br /> SITE ADDRpgcy�yn,,�yO— ///�t�T•/n' l^ I� "�^� <br /> Direc151n <br /> ZI Code <br /> HOME orMAILING <br /> a M.AILING ADDRESS (If Different from Site Address) I p /`+ 'n <br /> j v Street Number ` U&da VV <br /> CITY Street Na <br /> (lin QL STATE ZIP <br /> PHONE#1 UU�� EXT. APN# fL;AND USE APPLICATION# <br /> '20) 93-0 to 6-1 1�°1121�� L(P <br /> PHONE#2 ExT. DISTRICT LOCATION CODE <br /> ( o - tit 6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S Cp <br /> / CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ' ) <br /> 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, STATEandFEDERAL IaW� <br /> APPLICANT'S SIGNATURE: `� DATE: <br /> PROPERTY/BUSINESS OWNER LOY/ 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, 1, 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 to me Or <br /> my representative. -- � � J <br /> TYPE OF SERVICE REQUESTED: ��.9'I\ f(�f1 PAW U.11VT <br /> RE <br /> COMMENTS: R <br /> AUG 13 1018 <br /> E�RDONA4 QUIN COUNTY <br /> N& T; E MENTAL, <br /> P'��ENT <br /> ACCEPTED BY: t 1��t�t` d EMPLOYEE#: DATE: —�J 9 <br /> ASSIGNED TO: EMPLOYEE#: I DATE: yr <br /> Date Service Completed (if already completed): SERVICE CODE: m�/n PIE: O <br /> Fee Amount: ' Amount Pa' <br /> 15�2,60 Payment Date /S( <br /> Payment Type Invoice# Check# Recei ed Buy: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />