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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COWNER/OPERATOR <br /> \ � F/),;// <br /> ("'CHECK If BILLING ADDRESS� <br /> FACILITY NAME/ /1 f// �� <br /> Direction S L-IJ Y-7k,S V/ rn / � V J <br /> SITE ADDRESS/p�6Z N p�^ t�_I /„ y,� <br /> Street Number Stre¢t Name <br /> It, <br /> ZipCode <br /> HOMEor <br /> MAILING ADDRESS (If Different from Site Address) FZfn AV IYE <br /> J Q Sireel Number SVeet Name <br /> CITY o F A STATE eA <br /> ZIP 9,, <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT <br /> � LOCATION CODE <br /> ( ) (9 \ l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> "REQ ES <br /> BUSTTOR -�I��I��rr 111� <br /> CHECK If BILLING ADDRESS• -• <br /> 'SS N E e PHONE Ext' <br /> /] S ^ O7ni <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATEPA ZIP��a <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 thi app ication an at the w e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa s, T EDE ,/ <br /> APPLICANT'S SIGNATURE: DATE: X <br /> T� <br /> PROPERTY/BUSINESS OWNER OR OPERA /MA ER ❑ 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 /> t0 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 /> TYPE OF SERVICE REQUESTED: i L-S t <br /> COMMENTS: !:5"h4a" 51814 <br /> 4t,'16 OVA155 ys�q^N'�VOfR <br /> O�N\IN�OO' <br /> Uv 6 18 ? <br /> NV0N1 <br /> Mq' EMPLOYE #: DATE4ACCEPTED BY: —I <br /> D <br /> �-'1R ME <br /> AsSIGNEDTO: f-' (,co }'o EMPLOYEE#: DATE: +19— 1`7 <br /> Date Service Completed (if already completed): SERVICE CODE: / I PI E: `)-&0-2- <br /> Fee <br /> ZFee Amount: Amount Paid Payment Date t Th Z <br /> Payment Type Invoice# Check# Rec+ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />