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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�00 75q57 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name cityZI Code <br /> HOME or MAILING ADDRESS <br /> (If Different from/Site Address) <br /> vU� " /v C7 1� �w I k� Street Number Street Name <br /> CITY e)o i�vn.; ( " ( STAT /-4Z <br /> IP <br /> PHONE#1 EXT. APN# LANDUSEAPPLICATION# <br /> ('1110) 1 U 77 LA50/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> R! l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> �I�L I r/J)v)I t7 v V CHECK if BILLING ADDRESS <br /> BUSINESS NAME r eiZ PHONr# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> o71� A Z `�I�-0/vC1 4) <br /> CITY / ')/-I j�i�� $TATE/G/� ZIP L-y� <br /> BILLING ACKN'O'WLEDGEMENT: 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 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: t✓., <br /> PROPERTY/BUSINESS OWNER ❑ !TPERAT R/MANAGER ❑ OTHER AUTHORI7ED AGENT <br /> If ryM-0_;NT;,.,ricl 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 /> t 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. PA VA <br /> TYPE OF SERVICE REQUESTED: cj O c/ca. Le <br /> COMMENTS: <`J 29 <br /> 9 ?Q/� <br /> HE 1 qo TOVN <br /> PA�TM NT <br /> ACCEPTED BY: =�� EMPLOYEE#: DATE: G, <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comple d (if already completed): SERVICE CODE: 3 P/E: <br /> Fee Amount: �� � Amount Pai 3� U% Payment Date I�S <br /> Payment Type Ihecnvoice# CReceived By:�! ✓: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />