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/ . 3 ,D <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CAV? Fllk000lq S (00-7142uU <br /> OWNER/OPERATOR /I <br /> I V� ` A A CHECK If BILLING ADDRESS <br /> FACILITY NAME Do 90 1 � D'Vr--r I <br /> SITE ADDRESS V. I �II��ii I� 6)S O <br /> Street Number Dlrecnon Street Name city Zip Code <br /> HOME Or MAILING ADDRESS <br /> ��(if <br /> 1D(iifferent from Site Address) <br /> I./k "+1' OAkPtX, Street Number Street Name <br /> CITY $���.N\ SZIP 016 <br /> 2 07 <br /> PHONE#1 I V E%T APN# LAND USE APPLICATION# <br /> w« 5°16678 ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME j�n�(J_.!1 S t� PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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 I WS. <br /> APPLICANT'S SIGNATURE: <br /> DATE: D 6 a l ]A ly <br /> PROPERTY/BUSINESS OWNERS! 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, 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 pr0��_t0 me or <br /> my representative. /1YYc <br /> TYPE OF SERVICE REQUESTED: Fb()d <br /> COMMENTS: H <br /> Nfiw of )nw onsul"'bn SF,��QUOB ?�18 <br /> H RpA, OUN <br /> OFAgRNT,q� <br /> �FNT <br /> ACCEPTED BY: Q�/q/,t !/1 b EMPLOYEE M DATE: <br /> ASSIGNED TO: A IIr' EMPLOYEE#: DATE: Ur t tb <br /> Date Service Completed (if already completed): SERVICECODe 16O1Q� PIE:T/A907, <br /> Fee Amount: �� Amount Pai /5-, w Payment Date O S <br /> Payment Type dK Invoice# Check# / O Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 \n <br /> J C�` <br />