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SAN JOAN COUNTY ENVIRONMENTAL HEALTHH*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> �t EF} 777,�2-7 <br /> OWNER OPERATOR +1 ` CHECK if BILLING ADDRESS[Ell <br /> FACILITY NAME "�. ` l <br /> SITEADDRESS n � I v EI /IAVr / I � � <br /> L Iv 1 l.(Aif el Name "'7YY 2i Code <br /> [reef Number DlrecNon <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# <br /> G / D (] 1 � I BOS DISTRICT LOCATION CODE <br /> PHONE#2 EXT. <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 'XXI.r� CHECK if BILLING ADDRES <br /> I / PHONE# /,,/ EXT. <br /> BUSINESS NAME � g „ tj — 2 <br /> ,_ J /1_ Falx# <br /> HOME Or MAILING ADDRESS � Y' 4L'—(,lN <br /> ✓✓✓/// STATEZIP <br /> CITY r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or prOjact 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 e nd FES aws. y <br /> DATE: <br /> APPLICANT'S SIGNATURE: y— r� <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT IcsL Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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 <br /> environmental/site assessment information <br /> RTMENT ILS SOOn a5 It IS available and at the same time it IS p ylded,tD me Or <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA <br /> my representative. <br /> X17 ; <br /> TYPE OF SERVICE REQUESTED: ' <br /> COMMENTS: S N✓O,yQ�, 201? <br /> 1 EMPLOYEE#: DATE: <br /> ACCEPTED BY: <br /> /� / - EMPLOYEE#: DATE. <br /> ASSIGNED TO: W)y /`�b <br /> SERVICE CODE: PIE: <br /> Date Service Completed (if already completed): <br /> ! L <br /> Amount Paid Payment Date <br /> Fee Amount: <br /> Payment Type <br /> Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> 07/17/08 <br />