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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 91�70 <br /> OWNER/OPERATORCHECK If BILLING ADDRESS❑ <br /> D:1 hC. F-61 V,<-- <br /> FACILITY NAME <br /> SITE ADDRESS 311 Z <br /> !! ,/ <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY � ) STATE i- ,� ZIP � '2' <br /> PHONE#1 <f A EXT. APN# LAND USE APPLICATION# <br /> 01-7er . l0 -� ,� 1-73-010- 3'L <br /> PHONE#2 EXT, BOS DISTRICT LOCAT.IpN,CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /f <br /> 1 Tf� CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# Ext. <br /> HOME Or MAILING ADDRESS3- 3 FAX# <br /> CITY STATE C� ZIP ef�7 . <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentNA <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this pr � <br /> fr <br /> activity will be billed to me or my business as identified on this form. �f/' /� Q <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance withct I,-S 1 gOla& <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. E J�QU 18 <br /> �Ro iN CO <br /> APPLICANT'S SIGNATURE: :2z-- DATE: o NMFNr,�N�Y <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAG ❑ OTHER AUTHORIZED AGENT 11TMFNT <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: 1 1 4 ` r <br /> COMMENTS: <br /> — &K4V v <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 52Z PIE: <br /> Fee Amount: �Qc6 Amount P �]� Payment Date <br /> Payment Type Com. Invoice# Check# Recei ed By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />