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q '--5C) A-ck-/"— <br /> SAN JOAQUw. COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2ljb7�7�� <br /> OWR/OPERAT R �- <br /> ��� CHECK If BILLING ADDRESS O <br /> FACILITY NT <br /> -v— .=C�"& <br /> SITE ADDRESS <br /> t O ` S2 <br /> 3 '��S r t N m�� Direction �� treet Na e 9(( � G`��6�, Zi Code <br /> HOME Or MAIL ADDRESS-(If Differ t from it/e�Address) I <br /> 11 I��L Street Nu Street Street Name <br /> CITY STATE ZIP <br /> CIA- <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> n, <br /> PONE 2 EXT; BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU TOR <br /> CHECK If BILLING ADDRESS <br /> o- ' �l70-v-cc -PC— <br /> BUSINESS hAME PHONE# ExT. <br /> HOME or 1(LING ADDRESS FAX# <br /> CITY � ` hk l -2 STATE ZIP <br /> BILLING ACKNOWLE GEMENT: 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 bu as identified on this form. <br /> also certify that I have prepare this applic tion and that the work to be p ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stand rds, STAT and FEDE L laws <br /> APPLICANT'S SIGNA DATE: Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ff: 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 provided to me Or <br /> my representative. <br /> PA. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ` F <br /> O f <br /> a y�Rp& O/ <br /> HOFp A��4� <br /> ACCEPTED BY' �t EMPLOYEE#: DATE: <br /> ASSIGNED TO: � r 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: / L, <br /> Fee Amount: 1 1�L, — Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />