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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OP 52LO66: f7Jq o0o2 qG > ; i '; '9 <br /> OWNER/OPE TOR ,� \ �/ 40� <br /> �s r T 1 UI vf�LJ/- / A /// //I�d� CHECK If BILLING ADDRESS 1:1 <br /> FACILITY NAME I, It " / L li YV 4 /"` <br /> SITE AQ,DRESS TP V2wi-WI /2 <br /> 32-1 Street Number Direction Street Name e ^/ CIty Zip Code <br /> HOME Or MAILING ADDRESS (It Different from Site Address) —'6 (� <br /> Street Number Street Name �t� <br /> CITY / ,(LrT1 t� OP STATE ZIP 17 � it <br /> P�IE)1 )�/ 2 Exr. APN# LAND USE APPLICATION# l/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �- il DATE: <br /> PROPERTY I BUSINESS OWNER NJ� 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 th e <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment i 91 <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time it i5p rovided <br /> my representative. `/ <br /> TYPE OF SERVICE REQUESTED: ;�-;�:I C.S-Y �,/ �� V40 <br /> COMMENTS: /R L/ <br /> A���°�,y <br /> F'YT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z 114- <br /> ASSIGNED <br /> ZASSIGNED TO: EMPLOYEE#: DATE: i_ I I-7 <br /> Date Service Completed (if already completed): SERVICE CODE: (�(�_. ( PIE: Iti d <br /> Fee Amount: Amount Paid r�bD Payment Date /!Z._ <br /> i <br /> Payment Type �T_ / Invoice# Check# Receised By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07!17/08 <br />