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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A SERVICE R\EQ,UE T# <br /> VIES E <br /> OWNER/OPERATOR `y' I —^ <br /> �� I �1 � t—{ CHECK If BILLING ADDRESS <br /> FACILITY NAME I L A Jl 1 I tJ S I ','T1 <br /> SITE ADDRESS U y <br /> treet NumUer Direction ! , _Street Name I 1city I Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address)21 <br /> I I M/-n �t „v I ZS a <br /> �. �"� Street Number r / Street Name <br /> CITY ,1 STATE /t ZIP 01 t5 0, <br /> PHONE#'I ITS' IJ V EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` ` � der^� CHECK if BILLING ADDRESS <br /> BUSINESS NAME4. C� ����} S (' p - PY,ONvE# Ext. <br /> HOME or MAILING ADDRESS FAX# <br /> CITYL��n,N� STATE �D� ZIP C) J <br /> 1 , _'Iv S - <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. i <br /> APPLICANT'S SIGNATURE: DATE: I I <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proofbf 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is.6OVided to me or <br /> my representative. cA <br /> TYPE OF SERVICE REQUESTED: JbOd ( 0,, 5o (16410 CC <br /> COMMENTS: <br /> JUC ?3 20 <br /> 19 <br /> C�,un sN4r EN�ROINCouALy MpEAtENT <br /> ACCEPTED BY: L�T�� �� EMPLOYEE#: L- 90 DATE: 7 <br /> ASSIGNED TO: C'�/ /}� j� EMPLOYEE#: / 1• DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f 1(/�f PIE: 406), <br /> Fee Amount: _�/J Amount Paid ��� D Payment Date <br /> Payment Type Invoice# Check# 3 Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />