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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S(;" cozo�av <br /> OWNER/OPERATOR <br /> SJ AA5/r'j CHECK if BILLING ADDRESS <br /> FACILITY NAME Q �J G� <br /> IAI ar✓ SZ � <br /> SITE ADDRESS owDirection ��S�treet e Ci v`Z/i"C�od�e� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY Ca/v� / STATE _ A^ ZIP <br /> PHONE#1 EXT• # LAND USE APf PLICATION# <br /> (y13) -5--2,7-1Z6-�a6 9 APN <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME G PHONE# EXT. <br /> HOME or MAILIN ADDR FAX# <br /> 7o (2d If) <br /> CITYG ` *AlSTATE / A ZIP <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 e ork to be performed will be done in accordance with all SAN JOAQUIN <br /> th <br /> COUNTY Ordinance Codes, Standards,STATE FEDERAL I S. <br /> APPLICANT'S SIGNATURE: fy DATE: / / Y <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ CFt�i <br /> I{APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title/l/��II <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locat�t'i�Rt tiepb <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as g,�rr� t informaTitil+n7 <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time It I ON r <br /> my representative. HtrqLTH ONMFNT�NIY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: V t <br /> �Ere& 1 V" - oto-c'`f-� U-'i L' <br /> ACCEPTED BY: EMPLOYEE#: V DATE: / <br /> ASSIGNED TO: 1DA <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): $ y SERVICE CODE: / /E: �� <br /> Fee Amount: Amount Pa � D D Payment Date 1 7 �C <br /> Payment Type C)�p Invoice# Check# 93 7s Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />