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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty e of Business or Pr erty FACILITY ID# SERVICE RE UEST# <br /> 15�A 60-PyY7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME -���� l•/`�� , <br /> SITE ADDRESS o, <br /> Sheet Number D\ire�ctiJon Street Name Citv Zip Code <br /> HOME Or MAILING ADDRESifferent from Site Address) <br /> � \' Street Number Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ot\Q.e`1��- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR flaw <br /> To,K0 r" LCCHECK if BILLING ADDRESS E] <br /> BUSINESS NAMES <br /> PtQ # EXT. <br /> I o k1 os (� <br /> HOME or MAILING ADDRESS Taf 1<e y— FAX# <br /> CITY L STATE I,� ZIP �C,/_ <br /> BILLING ACKNOWLEDGEMENT: 1, 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 thisap lication and that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S A d F RLI w <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 Tille <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 i$�pr vided to me or <br /> my representative. //"''' @@Jim, •+� <br /> TYPE OF SERVICE REQUESTED: �/� I�`l t K "' <br /> lzr- <br /> COMMENTS: a1 f <br /> ,/� i p SAtV✓O A Z�jB <br /> ��e FW , QUI/C <br /> 0� H �TN O"MFf�°iJIV�, <br /> OFpgRrtiq1J <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 ,/lVt EMPLOYEE#: DATE: !/ <br /> Date Service Completed (if already completed): SERVICE CODE: �) � ' PIE:, <br /> Fee Amoun : 2`(f(J Amount Paid, �� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />