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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cc � re �v-1 SSC r S �$D �-` <br /> OWNER/OPE OR ^ <br /> /t /�I ���; rlCHECK If BILLING ADDRESS <br /> FACILITY NAME � �T,�` !e ,� �M 1 /�e c �'���+ <br /> ! Y J 1 <br /> SITE ADDRESS ' ��h e <br /> 3cr7" ��� SSC � dvr � 5� <br /> umber Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) � <br /> 70 L' / >7! 0 C—f /lStreet Number Street Name <br /> CITY \ �C / / Y\, $C '4 ZIP C <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (; p 2y,-i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) cQs C'u <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /) r e f /A)/�(`' �e� <br /> j-` (J\ � 1 I I h CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> -15 ���eo � ` <br /> I ce C rCa el )'.� ., L.! - L 1 W;5 <br /> HOME or MAILING ADDRESS FAX# <br /> c 1 f7C-IN Y`0 C (,f ( ) <br /> CITY -�A Q L y� STATE(7 L) ZIP `1 <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 tome or my business a ' tified on this form. <br /> I also certify that I have prepared this ap i-tion and t t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST TE and FEDE AL a s. Ll <br /> APPLICANT'S SIGNATURES Gam/ {� DATE: Q <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 assesssmeei��t�fi <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS <br /> my representative. NES <br /> TYPE OF SERVICE REQUESTED: �tns o <br /> COMMENTS: <br /> ' EWIRONMENTU LT`( <br /> HFALTH DEPART <br /> ACCEPTED BY: / (V�� S EMPLOYEE M /� DATE: /5 <br /> ASSIGNED TO: <br /> Vi' <br /> EMPLOYEE M l! DATE: P <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:— <br /> Fee Amount: Amount Paid Payment Date t/ <br /> Payment Type Invoice# Check# Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />