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SAN JOAQL BOUNTY ENVIRONMENTAL HEALTH L ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> KM �,m l CHECK if BILLING ADDRESS <br /> FACILITY NAME `` -'1 , ` l <br /> SITE ADDRESS �V � r�a� S GtCV "Code Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different rom Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (010 IN) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1�11 <br /> K S`� CHECK If BILLING ADDRESS 13 <br /> BUSINESS NAM , PHONE# EXT. <br /> � Sc�'CyA\ �nv�- A -et -t E -23 6 0 <br /> HOME or MAILING ADDRESS FAX# <br /> N <br /> CITY C STATE ZIP 01.5 <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,ST DERAI laws. <br /> APPLICANT'S SIGNATURE: DATE: Q IS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY.proof of authorization t0 sigh 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 It is available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �✓ �C U `�, <br /> COMMENTS: � <br /> G ti <br /> SO <br /> PD <br /> ACCEPTED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: W EMPLOYEE#: DATE: oz- r 5 <br /> Date Service Compieted (it alrea Completed). SERVICE CODE: G�Q� P I E: too-) <br /> FeeAmount:IX / vAmount Paid ��� Payment Date zR (.) �S <br /> Payment Type MCI Invoice# -G� ma 13(o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />