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SAN JOAQUINtOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property p FACILITY ID# SERVICE REQUEST# <br /> I UOV SfiDYe I �ICU(✓� ��i �3 S��D'I�j� S�J <br /> OWNER/OPERATOR ,err <br /> CHECK If BILLING ADDRESSI� <br /> FACILITY N\\AME <br /> SITE ADDRESS Q O 1 1 <br /> Street Number Direction -J Street Name 1 city Zip Catledw <br /> HOME or MAILING\A�DD�R/E-SS (If Different from Site Address) <br /> `""t-�\�• ` >treet Numbe.1_ Street Name <br /> CITY STAT ZIP <br /> aSaHo <br /> PHONE#1 FxT. APN# LAND USE APPLICATION# <br /> cam a a� -� -1 )'1 <br /> PHONE#2 EXT. BGS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ``__ <br /> U.kV S�'1A.rdltl S�V�S� CHECK If BILLING AD DRESS© <br /> BUSINESS NAME PHON # EXT. <br /> Li Dov _ 2- -7q 14 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY y 4 STAT <br /> E ZIP q S-a Ll L <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 TATE and FEDERAL IaWS. <br /> APPLICANT'S SIGNAT URE: DATE: <br /> PROPERTY I BUSINESS OWNER PERATOR/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, 1, the owner or operator of the property located at the ¢We <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment inf . <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time it is provided� E,AY] <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: UUGpy1w1MHbn ��1�•C� V90 <br /> E16 <br /> D <br /> COMMENTS: HE/1L r, COUNTY <br /> H TEPA TME <br /> NT <br /> ACCEPTED BY: a Apactmeva Yl A EMPLOYEE#: DATE: / <br /> ASSIGNED TO: aHy I V EMPLOYEE#: DATE: Ill <br /> Date Service Compleed (if already completed): SERVICE CODE: I 'C I PIE: l Z <br /> Fee Amount: Amount Pairvh7 rj ,N 1 Payment Date `' <br /> Payment Type Invoice# Check# Received By; /.. <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />