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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 /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 11 1 <br /> azSITE ADDRESS , ?, 4 4 <br /> Street Number Direction C= Street Name C([ Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Cl <br /> t"j p l Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( t) G 6 - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORlU�n <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# <br /> '=-M <br /> r�I ./� \ C/� EXT. <br /> EXT <br /> HOME or MAILING ADDRESSFAX# <br /> -!st O Wovvr--'1e <br /> CITY STATE(l n ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, `oppe—rrator or authoriized 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: � � �y_�� DATE: G - L <br /> PROPERTY/BUSINESS OWNER EI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tillc <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 provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Co V1 <br /> Ace <br /> COMMENTS: V vV wv"; \P - to <br /> SgN✓OA�O 6 4018 <br /> FNS QUA <br /> H�LryQ MF�rUNA I Ty <br /> ACCEPTED BY: EMPLOYEE#: DATE: FNT <br /> ASSIGNED TO: , t/�/�n , EMPLOYEE#: DATE: <br /> Date Service Co leted (if already comp eted): SERVICE CODE: DO PIE: I O <br /> Fee Amount: l q D'o Amount Paid 52 _ Payment Date <br /> Payment Type �'b It Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 5 <br />