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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT F <br /> l SERVICE REQUEST <br />,I Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR a CHECK if BILLINCy ADDRESS <br /> FACILITY NAME <br /> SlTEADDRESS l 2— <br /> Street <br /> Street Number Direction Street Name Zip Code <br /> HOME Or MAILING A ESS (If Difflent from Site Address) I <br /> Street Number Street Name <br /> CITY a STATE ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> 2091 '9 (Z4- <br /> PHONE#2 1-!X7• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRES51...1 <br /> BUSINEss NAME PHONE# tixr. <br /> 'l <br /> HOME or MAILING ADDRESS FAX# r <br /> CITY STATE Z.IP <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 associatedwith 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,STA71 and FEDERAL laws. <br /> t <br /> APPLICANT'S SIGNATURE: DATE: - 3 t l <br /> n <br /> PROPERTY I BUSINESS OWNED OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ! <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to sign is required Ti lie <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 environmentallsite assessment information <br /> to 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. r P <br /> TYPE OF SERVICE REQUESTED: C�� l,c,�k'l Lt,l gk�'loln —( • <br /> CoMMEN75: L4 u^/ e, @ i..r��S�+�+�. MAY 3 ' � <br /> 12p» <br /> yV 4LT I�ONtfz C►UNTY <br /> N OEpaRMTAO jqL <br /> ACCEPTED BY: M( '�r�{ EMPLOYEE#: DATE: f L <br /> ASSIGNED TO: N�,r1' a EMPLOYEE#: DATE. rj7--5tl_ <br /> Date Service Completed (if already completed): SERVICE CODE: ��j P I I <br /> Fee Amount: 00 Amount Paid 1 J � V D Payment Date 51-3`// <br /> Payment Type ` Invoice# Check# Received By:/J,/ <br /> EHD 48-02-025 5R FORM(Golden Rod) <br /> 07/17/08 <br /> i <br /> V <br /> a <br />