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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 162OWf� S f-7 C,� SC-00 -7 9 (3- 162- <br /> OWNER <br /> NER/OPERATOR C <br /> C1 \v� CHECK If BILLING ADDRESS <br /> FACILITY NAME C <br /> SITE ADDRESS 2�'\-A OAC T r m c- <br /> c1 S <br /> Street Number Direction Street Name ,J city Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (-71y) ���- l - � 2 -1 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) oo S o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEu-'C PHONE# EXT. <br /> C h e ;�� S� v� 2 2 2 71 <br /> HOME or MAIL I G ADDRESS FAX# <br /> Q 2 Z9 -2- <br /> CITY <br /> CITY 1'�/ QSTATE C A- ZIP �. 2- 2 <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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It 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 the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is provldw to me or <br /> my representative. _ A <br /> TYPE OF SERVICE REQUESTED: Q C ��+ <br /> tr <br /> COMMENTS: NO <br /> e-m G,,, \ _ SAN I/Ofti/tv C 2118 <br /> EN <br /> (� HSC H VIPOIVYROIJ <br /> �C 7-y <br /> 7- <br /> ACCEPTED <br /> ACCEPTED BY: �r\ EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� p EMPLOYEE#: �v�`rDATE: <br /> Date Service Completed (if already SERVICE CODE: S`2 P/E: 1 bV <br /> Fee Amount: U Vl,{ Amount Paid Payment Date - - L6 <br /> Payment Type C��l� Invoice# Check# Z 72,�,gw Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />