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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> �& cv'le c"�'� S'40 M Iq <br /> OWNER/OPERATO <br /> 1//`- v CHECK If BILLING ADDRESS <br /> FACILITY NAME ��nl /L /�� <br /> 0q <br /> SITE DR4 V l <br /> Street Number I Direction `— �V Street Nam ity, <br /> Zip C6de <br /> HOME Or MAILINGADDRESS (If Different from Site Address) <br /> —L�e ICAJ Set Number Street Name <br /> CITYC)CA L' STATE <br /> C ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> Q JU C�,arn b-G ! <br /> HOME or MAILING ADDRE S FAX# <br /> /' r �rvfl S <br /> CITY I All, <br /> $ TE ZI <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: DATE: <br /> PROPERTY/BUSINESS OWNERQ�the <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS nBILLING 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 a <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infor o <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 I glr&4. <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: u . <br /> , ff <br /> COMMENTS: At'�41,r'ROQuZ,V 41, <br /> T,YL�)O�F p�Hry <br /> FNT <br /> ACCEPTED BY: �j EMPLOYEE#: X ' DATE: <br /> ASSIGNED TO: vO&Ll EMPLOYEE#: U rr// DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: f <br /> Fee Amount: I Amount Paid /�. 0 D Payment Date <br /> Payment Type Sti Invoice# Check# d�� ec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �S <br />