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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 R 00 IIAA� <br /> OWNER/OPERATOR <br /> ' CHECK If BILLING ADDRESS <br /> J -0 <br /> FACILITY NAME / <br /> �- <br /> SITE ADDRESS yr / <br /> Z7 Street Number Direction ` e�t .mv,v - Cit(D zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) A Y <br /> Street Number Street Name I vp <br /> CITY STATE ZIP , A <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# O <br /> 3Zt- 272 18 <br /> PHONE#Z EXT. BOS DISTRICT L Jia Fp ANO T_ <br /> CONTRACTOR / SERVICE REQUESTOR ir <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> 1 <br /> PHONE# EXT.BUSINESS NAME <br /> 9- <br /> HOME Or MAILING ALJDJkESS FAX# <br /> �b /V (Cv.t1 ( ) <br /> CITY yj STATE ZIP 9 <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 tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,STATE an DERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE:-� <br /> PROPERTY/BUSINESS OWNER MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If 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 /> 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: 2— 4,P— -Pay ekA) <br /> COMMENTS: .T_ 1c—c <br /> ACCEPTED BY: �� �J EMPLOYEE#: 1 DATE: <br /> ASSIGNED TO: EMPLOYEE#: l DATE: <br /> Date Service Completed (already mpleted): SEP',— _ 2, 4 P/ : 60/ <br /> Fee Amount: Amount P D(� Payment Date r `� <br /> Payment Type C/E Invoice# Check# /D S,2--- Receive By: <br /> EHD 48-02-025 � ���1� / SR FORM(Golden Rod) <br /> 07/17/08 J i G t t+�_ �/I c o?77 <br />