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SAN JOAQL..A COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _7 7:5 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME I r i <br /> SITF�DD!F6 Street Number Direction �C <br /> HOMES orrr MAILING ADDRESS (If Different from Site Address) <br /> P, �( .2 r Street Number Street Name <br /> CITYC ' STATE ` ZIP <br /> �� <br /> PHONE#1 EXT• N# LAND USE APPLICATION# <br /> (310)qqq- l(-lqb 70 c <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CO <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> n O /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME I� PHONE# EXT. <br /> 00� 7 -,2D�0 <br /> HOME or MAILING ADDRESS (� FAX# <br /> ��� <br /> i1 1 ( ) <br /> CITY ` +VcKicn $TATE ZIP 01 lJ 1 <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 ap lication and that th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA and FELE L I S. <br /> --- n <br /> APPLICANT'S SIGNATURE: y'j DATE: l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT n /� <br /> If APPLICANT is not the BILL NG PARTY,proof of authorization to sign is required Tire <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 environmental/site 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. <br /> TYPE OF SERVICE REQUESTED: F60d (11 - �Y <br /> COMMENTS: �CiVP® <br /> 0 c�L'36 Cr ��C 0720, <br /> RCCA TViRONME OUNn, <br /> N <br /> ACCEPTED BY: EMPLOYEE#: DATE: eN /"7 <br /> ASSIGNED TO: F1 EMPLOYEE M DATE: 12. 7- J7 <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: — <br /> Fee Amount: Amount Paid Payment Date 1 <br /> Payment Type 1 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />