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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> • CHECK if BILLING ADDRESS <br /> FACILITY NAME ce,1-4 <br /> Q <br /> SITE ADDRESS 60 Os' �j Nv Ei L--ova 4 ��D <br /> Street Number Direction , '1 S'treelt Name city ZIv Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT* APN# LAND USE APPLICATION# <br /> , o6eb <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> 2-(11 3Co0��-b <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 9 CHECK If BILLING ADDRESS <br /> BUSINESS NAME l l' PHONE# EXT. <br /> e FV 91016 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY L-0 STATE ZIP (� Jt <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 /> 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 FEDER laws. <br /> APPLICANT'S SIGNATURE: DATE: — O�S^ ' <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr� to me or <br /> my representative. ryry�I <br /> Ar <br /> TYPE OF SERVICE REQUESTED: S �� <br /> COMMENTS: R <br /> 0 g 7n <br /> f. <br /> UfN CO �9 <br /> F'gLTj�0 pfz4rfA <br /> Py <br /> ACCEPTED BY: 1 �� � EMPLOYEE#: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE P/E: I UO2 <br /> Fee Amount: C2 _ Amount Pai /S"? dC/ Payment Date / <br /> 1 <br /> Payment Type Invoice# Check# Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> o N � S <br />