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i <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property {� FACILITY[D# SERVICE REQ(U�ESSyT.,# �I <br /> 1 <br /> 'FiRMI 1UJq <br /> OWNER I OPERATOR <br /> t 7 CHECK If BILLING ADDRESS <br /> F <br /> = �fjr%- J& <br /> SIT S ' <br /> 1N DS-ekvJ2. <br /> Street Number Direction Street Name �� ~ �� Tq!g-3-37 <br /> CI ZI Coda i <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY t STATE zip <br /> PHONE#1T APN# LAND USE APPLICATION <br /> `b? # <br /> ( 7�G- 3cno <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE 1i <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR LL �+ <br /> CHECK if BILLING ADDRESS <br /> iA <br /> BUSINESS NAME I , PHONE# EXT. 1 <br /> i <br /> HOME or MAILING AD ESS FAX# <br /> ( ) + <br /> CITY TATE 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. 1 <br /> also certify that I have prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATE ar F�EDERA . I <br /> f <br /> APPLICANTS SIGNATURE: DATE: 1 <br /> PROPERTY/BUSINESS OWNER PERATOR I 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 t0 me Or { <br /> my representative. A I <br /> i <br /> TYPE OF SERVICE REQUESTED: <br /> E2od. 66-n,-(,WM <br /> COMMENTS: NO I Yi <br /> 07 <br /> MANvwwr SAN z �6 <br /> FryI L'i IV <br /> hEA� H DE ARTS k , <br /> E+1T <br /> ACCEPTED BY: © EMPLOYEE#: DATE: I 117/1 <br /> { <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: {!O I `PIE: lY0� <br /> .01 <br /> Fee Amount: Amount Paid ,�� Payment Date 1117 h <br /> t. <br /> Payment Type Invoice# Check# Received By:� � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />