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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 1 i. ^ f+ CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME y <br /> SITE ADDRESS ( 7�� % C V'}U UC� C r L7 <br /> Street�Nulmler Direction Street Name Ci Zi Code <br /> HOME r MAILING ADDRESS (If Different from Site Address) <br /> D �'l.� Street Number Street Name <br /> CITY STATE ZIP <br /> I ��0✓ C\ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) C- C C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r,t N V\ CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` �f PHONE# EXT. <br /> (?c°) z 9 _'�z((o <br /> Hon or MAI NG ADDRESS FAX# <br /> J " '-� ( ) <br /> CITY 1� 1. f STATE /1� ZIP 6- Z 5-3 <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 /> 1 <br /> APPLICANT'S SIGNATURE: >�,t(,;/ . ,v— DATE: �— j? <br /> PROPERTY/BUSINESS OWNER❑ OPER OR Jr MA AGER ❑ 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: J 1 e V� <br /> 1 <br /> COMMENTS: J <br /> ` <br /> SANS p ? ?® <br /> FNViAQUiN <br /> H TS�pPgRT 7-k�N <br /> ACCEPTED BY: EMPLOYEE#: DATE: -7 <br /> ASSIGNED T0: 1 CA EMPLOYEE#: DATE: -7 <br /> Date Service Completed (k already completed): SERVICE CODE: — P I E: <br /> 1 . 10 <br /> Fee Amount: Amount Pa b Payment Date '1 <br /> Payment Type V Invoice# Check# S /Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />