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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> C U V t S� J``•I CHECK If BILLING ADDRESS <br /> FACILITY NAME \ t <br /> SITE ADDRESS / L <br /> (( 1 C Li. �' c, C V r�F►,Ftp !-fi w1 cl 2 l G <br /> Street Number Direction Street NameCity Zi Cade <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> 17 �� C r`� Y 1 Street Number Street Name <br /> CITY STATE ZIP D U <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2,o q) y � � ; 3�2 <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ I <br /> V � Ct v1 c-, CL I CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME VV 1J\� C r�C �l ( r PHONE 0 ` O H _2 -T <br /> HOME Or MAILING ADDRESS , FAX# l� <br /> CITY STATE ZIP Ct <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: �%` 1— -2,U— <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 locatAw Stheabove <br /> site address, hereby authorize the release of any and all results, geotechnical data andlor environmental/site asseson <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It ISjmy representative. �_ <br /> TYPE OF SERVICES R�EQQUESTED: � Q C tv�- r 3 <br /> QA <br /> COMMENTS: V Y 1 CA f 1y 0� w��/l.�'VShFq�V RQN/N CO N <br /> Ty p�pq� f?' <br /> ACCEPTED BY: \,\A EMPLOYEE#: DATE: <br /> ASSIGNED TO: V+ ��nV lJ/1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 1 O� Amount Paid I Payment Date tr 3Q l <br /> Payment Type Invoice# C ck Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 1�1 lQ U7 <br />