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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ice (�00 216) <br /> OWNER <br /> /OPERATOR \ _ <br /> ` v K1►r�\ ....J 1�►5C� CHECK if BILLING ADDRESS <br /> LLJ <br /> FACILITY NAME No, LO In <br /> SITE ADDRESS�C '%^-/ �ti ca�T lr r _ �� - Tr' C, S 7 <br /> street Number Direction Street Name Cf Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZI <br /> PCA <br /> S-5-7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 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 /> 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 FED AL laws. <br /> r, <br /> APPLICANT'S SIGNATURE: - O DATE: 2-L2-4- <br /> PROPERTY <br /> /BUSINESS OWNER OPERATOR/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 assessmente'qformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS prov'cre, or <br /> my representative. RR �iJ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: lJ Y r"' `�n�',�/ �('�. S� �✓O � �O, <br /> �94TtioFpgRN <br /> MFHT <br /> ACCEPTED BY: EMPLOYEE#: DATE:-�2- 2I 1 <br /> ASSIGNED TO: /� u ( 1 EMPLOYEE#: DATE: 'Z 2'7 <br /> ri <br /> Date Service Completed (if already completed): SERVICE CODE: 01c, I PIE: <br /> Fee Amount: I , Amount Paid-q) �� Payment Date 7117 <br /> Payment Type Invoice# Check# yyReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />