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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busingas or Property FACILITY ID# SERVICE REQUEST u <br /> OWNER/OPERATOFJ <br /> f � CHECK if BILLING ADDRESS <br /> FACILITY NAME ,\ <br /> SITE ADDRESS Sys yO o' ^ fly�ji(lTy /..�r.� 4,1 / <br /> Street NCC.mbber D rection hw G` S[�reet NVa'me �C(i �zi� odbe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EKT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> `^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME `.�S / PHONE# O � EnT. <br /> HOME or MAILING ADDRESS FA% <br /> fo 80 ( ) <br /> CITY / _ _ ��a"1 '9 S r ZIP <br /> BILLING ACKNOWLEDG ENT: 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 1 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,S nd FEDERAL laws. /'' <br /> APPLICANT'S SIGNATURE: per_ '" �ti DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ff� Q' <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 provt0 me or <br /> my representative. & PA <br /> TYPE OF SERVICE REQUESTED: C/ D <br /> COMMENTS: <br /> AY?g 20 <br /> Mf �QU/NCOU <br /> EACTH p p�M N <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date aq <br /> Payment Type a� Invoice# C,p7ck# ��� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />