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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 07/7 7--C' <br /> OWNER/OPERATOR{� ' ` /� � <br /> ( ,�)i / i aE{ A CHECK If BILLING ADDRESS E] <br /> FACILITY NAMElV`v(�� L�/l�t <br /> SITE ADDRESS 1� Vii f �►' C1§ 2J L� <br /> Street Nu ber Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 13S-Q, ��I �f✓ ' /P U �� <br /> Street Number I Street Name <br /> CITY S—/ V(/ I+�i� IL� V r STATE 7 ZIP <br /> PHONE#1 ExT• APN# LAND USEAPPLICATION# <br /> oi3-0�-w <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> r CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 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 SIGNATUR�E{: - DATE: <br /> PROPERTY/BUSINESS OWNER,iLJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign l5 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as It IS available and at the Same time It IS providedto me or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: ' <br /> G� FC T <br /> D <br /> COMMENTS: SqN AR 18 2 15 <br /> EN►AQU11►C <br /> HEq�TH DE ARTM N7y <br /> Np <br /> ACCEPTED BY: EMPLOYEE#: DATE: S <br /> ASSIGNED TO: - EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: n PIE: ' 02— <br /> Fee Amount: `� Amount Paid 3d n Payment Date 3 � lS <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />