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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -a: 0-,ro-iNm Q-a,4- z5e-cogDS-32 <br /> OWNER/OPERATOR Y/ CHECK if BILLING ADDRESS <br /> FACILITY NAME ca <br /> SITE ADDRESS ! 75 q'jrzL1() <br /> (Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY a STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (\�, ^ � <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME rv-1 EXT. <br /> Oyt <br /> HOME Or MAILING ADDRESSPD n �� `t^ ( <br /> NOFAX ) <br /> CITY I . ' (/�v �L/ STATE OA ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all site andlor 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 F <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/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 assessment information <br /> t0 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. <br /> TYPE OF SERVICE REQUESTED: WAAfl <br /> COMMENTS: C .+ 40 w <br /> Vu�/ T S <br /> h FM°Ro UYV <br /> �9lTyoF gy�N��H'Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: N <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: 'C� Amount Pai /S ,U Payment Date <br /> Payment Type ✓ Invoice# Check# Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />