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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII ITY ID# gRVICE REQUEST# <br /> 1 � (Pq 17A <br /> OWNER/OPERATOR2 I t in Wo <br /> DI I , 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Zh'l�os �UL <br /> SITE ADDRESS n7Le /T\ `\ <br /> 1 ' �etNumber Direction �� Street me it zip C � <br /> HOME or MAILING ADDRESS (If Different from Site Address) ��/- <br /> tree[ umber f ( �( Street Name <br /> CITY h O� STATE � ZIP <br /> PHONE#1 \ EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I_ I i /1WO CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 /> I 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: ��� DATE: r e �-2�� 2 0 J <br /> PROPERTY I 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 atShe above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmenion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS prove <br /> my representative. C <br /> TYPE OF SERVICE REQUESTED: ,��"OC, <br /> COMMENTS: AL <br /> do, <br /> h 20 <br /> �� <br /> iR /N <br /> Th'�pq�C-14 <br /> MFNT <br /> ACCEPTEDBY: LottArOI (5,�,oer EMPLOYEE#: DATE: , — q <br /> ASSIGNED TO: M All EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:,l <br /> Fee Amount: Amount Paid '�� OJ Payment Date 1d Zg �- v <br /> Payment Type ' � Invoice# C ck# Receive By: <br /> EF-ID 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />