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SAN JOAQUInI COUNTY ENVIRONMENTAL HEALTH C I=rARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 600 ��� �� P <br /> OWNER/OPERATOR t <br /> 61 ` io CHECK If BILLING ADDRESS <br /> FACILITY NAME I v ` <br /> SITE ADDRESS <br /> Street Number Direction Street Name Zip Code <br /> HOME o AILING ADDRESS (If Different from Site Address) <br /> Street Number P'Jrilame iA <br /> CITYjl 'R�n u�l ` �i'STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> �L9 151 - � � 16 X 0 ) 0 <br /> PHONE#2 EXT. BOS DIST IC LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (� A � ��1\ \�1 � 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME l 'n n PHONE# � _ 1 r _-F-XT, <br /> V t �:11 VV � L9,0 <br /> l� <br /> HOME'r IMPAILING ADDRFS_ r 1 FAX# <br /> CITY STAT 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _4 /G ATE: <br /> PROPERTY/BUSINESS OWNER Icy OPERATOR/MA AGER ❑ / OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is riot 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 PA above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessorgqtt I" <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It IS prd�C eZX•r <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 2 <br /> COMMENTS: do <br /> COUN <br /> vi TyOEP F <br /> C�'�G ✓1C'2 G� Y 112 1" �R14feN7 <br /> ACCEPTED BY: �12 CIA EMPLOYEE#: DATE: <br /> ASSIGNED TO: G r C EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /j , PIE: <br /> I 0 <br /> Fee Amount: C6) Amount Paid Payment Date <br /> Payment Type r Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />