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SAN JOAQUIN UOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property „ FACILITY ID# SERVICE REQUEST# <br /> ow �3�- ' <br /> OWNER/OPERATOR <br /> MD \ — 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME l,\ <br /> SITE ADDRESS L <br /> Street Number I Direction ` Street Name city \ lZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SQ wl Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (10�) _ G3� & [3Ci '2Z'90 <br /> PHONE,2 EXT. BOS DISTRICT,r\ LOCATION CODE <br /> �J <br /> 0-7— <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ;/ O <br /> \ CHECK If BILLING ADDRESS <br /> BUSINESS NAME � PHONE# , ` 2 <br /> EXT. <br /> cK --co-3 YY <br /> HOMECor MAILING ADDRESS �II FAX# _l J <br /> CITY �.}-Q(:-Ii D V� STATE C,A ZIP a �-2-0 <br /> 2- Z <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: O DATE: Z— <br /> PROPERTY/BUSINESS OWNER M 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 assessme I formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time it is pro or <br /> my representative. ``pp�� <br /> TYPE OF SERVICE REQUESTED: )� I- J-j U <br /> COMMENTS: <br /> S H°"I 201 <br /> y�CTHO pMCO(JN <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 I " <br /> ASSIGNED TO: I�- EMPLOYEE#: DATE: 212Q I Y <br /> Date Service Completed (if already completed): SERVICE CODE: CX-0 PIE: <br /> Fee Amount: L I Amount Paid /s'? Payment Date <br /> Payment Type � Invoice# Ch ' gOS�— Received By: zp <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />