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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �� OO FACILITY�# SERVICE <br /> �R(EQUEST� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME I! <br /> u j <br /> SITE ADDRESS DT) <br /> 'T�I 1l (( /f `71 S 3: i1 <br /> "Street Number Direction ' `�`�` '` Street Name �—t'l`- Zi Co-dee J <br /> HOME Or MAILING ADDRESS (If Different from Site Address) I S 3Z l�� � <br /> 1 Street Number Str et Name <br /> CITY CELn STATE ZIP /-,r ,�Jnq <br /> PNE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#Z _bCEXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS ff <br /> X7. <br /> ff <br /> BUSINESS NAME PHO) E <br /> HOME or MAILING ADDRESSFAX# <br /> l ) <br /> CITY STATE �- ( ZIP <br /> A G <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: 2U I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 providedp ine or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 5wy S A I <br /> COMMENTS: JUAV AD <br /> 'Dcot <br /> "t N7.y <br /> T <br /> ACCEPTED BY: EMPLOYEE ��( / DATE: / n y/ /C <br /> ASSIGNED TO: La In 0 e EMPLOYEE#: vv DATE: if i� <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: `I/l/'� <br /> Fee Amount: a'Q� Amount Pai /S Payment Date �o 21, lY 1. <br /> Payment Type Invoice# ` Check# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 19 4-3� <br />