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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUST# <br /> wafe Ak(,0 IT-u ca=n c �C5 (a <br /> OWNER/OPERATOR) <br /> MM- CHECK If BILLING ADDRESS E] <br /> FAC AME <br /> SITE ADDRESS d , �t <br /> 1 C o Street Num <br /> / ec <br /> ler D'irvtion STtrYeet Name ( Ci.'�CX\ Zip 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 /> 6)�) G('A U acs <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � eL - CQJ� DATE: I`1 I c�kJl l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 4THER AUTHORIZED AGENT ❑ PS <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 iriformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provide 4 <br /> my representative. <br /> n SII <br /> TYPE OF SERVICE REQUESTED: ct-1 C up SU 1 toti CIT-) �O <br /> COMMENTS: 9 <br /> P45 N N�ORo U/N t:0 f9 <br /> L S j D 1 o g 6 Z �cryopAR � r, <br /> r <br /> ACCEPTED BY: e'3 EMPLOYEE#: wl DATE: �—//: I GI <br /> ASSIGNED TO: „e� EMPLOYEE#: l v 1 `� DATE: —/JI` 1 <br /> Date Service Completed (if already completed): SERVICE CODE: C)!_ P//E::� 7 <br /> Fee Amount: � Amount Pai �sa d Payment Date <br /> Payment Type Invoice# Check# b Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />