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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SVA-n a 5 <br /> OWNER/OPERATOR , CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDREES�yS(/ �/ l� 0 I,� <br /> '-133 �J Street Number Direction / Street Name 1 Cl 1 Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ✓v / 5 <br /> Street Number Street Name <br /> CITY STATE ZIP c <br /> PHONE#1 EXT• APN# LAND USE APPLI <br /> PHONE#2 EXT. BIDS DISTRICT TION NODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M I✓�� �ylf/C CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 2S 5-61 fL-1 <br /> HOME or MAILING ADDRESS FAX# <br /> 7/9 G. 1,10 'A 5f ( ) <br /> CITY 5- o C &t.n STATE C� ZIP -7 Z(i <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: zz- % � DATE: <br /> PROPERTY I 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 ipf t n <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provided a <br /> my representative. G �'411:Ic <br /> TYPE OF SERVICE REQUESTED: Aab un <br /> COMMENTS: Sq IV✓ y /, <br /> `�fj 'n ENS/ /VC <br /> �VV WY <br /> Lk ' "`��Y ' N�CTy�EpMFIyT��ViY <br /> qTM �T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: (4 _ ' G{ 17 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> -3 <br /> Fee <br /> Fee Amount: / Amount Paid / Payment Date * - <br /> Payment Type - Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />