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SAN JOAQUIN G dNTY ENVIRONMENTAL HEALTH DEPZMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (p qq574 <br /> OWNER f OPERATOR 5 ���T CHECK if BILLING ADDRESS 6.J <br /> �ZA <br /> FACILITY NAME <br /> SITE ADDRESS <br /> (Street Number]—Direction Street Name Ci ZI Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number I C� et Name <br /> {�.Ir S „ zip -?Tb <br /> -9 <br /> TY w <br /> Tg,TE <br /> IY? 1 L 19 rT!±T <br /> i PHONL#1T APN# LAND USE APPLICATION# <br /> I <br /> (SIO) <br /> I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( U 3 Z� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR a � CHECK if BILLING ADDRESS <br /> I BUSINESS NAME Jf(� m4PHO/E#EEXT' <br /> ho nt'-eo ZZV 6(16 � <br /> HOME or MAILING ADDRESS G y `/�7 FAX# <br /> ' CITY ��` / f STATE Z!P -��® ' <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 FEDE" ) 61 <br /> a <br /> APPLICANT'S SIGNATURE: ---` DATE: S �> /—/ <br /> PROPERTY/BUSINESS OWNERIK OPERATORI MANAGER ❑ OTHERAUTHORIZED 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 provided to me or <br /> r my representative. p <br /> TYPE OF SERVICE REQUESTED: �� RE�ely r <br /> . COMMENTS: C1r 3 12016 <br /> ae o wyn er" <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> r <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed: SERVICE CODE: f P1 E: <br /> Fee Amount: Amount Paid' �� Payment Date -5f31/1 <br /> Payment Type Invoice# Check# Received By:f � <br /> EHD 48.02-025 SR FORM(GDiden Rod) <br /> 07/17/08 <br />