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-F rq <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> atzalf <br /> � t %D <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L 1 7 1G 0 1 at <br /> Lu <br /> SITE ADDRESS � ��\\�n [�{•� L"t(-" <br /> 1 Street Number CH6,lon LL %VI(1$rya�lMame� � N i (� �{[)"Z.Q-I <br /> HOME Or MAILING ADDRE♦♦SS (If Different from Site Address) <br /> /rC Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1T• APN# LAND USE APPLICATION# <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME t— �( 1 PH NEIf Ezr. <br /> L)ON <br /> HOME or MAILIN ADDRESS FAX# <br /> 2 J ( ) <br /> CITY STATE / 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 ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT and FEDERAL laws. 2 ,t Q <br /> APPLICANT'S SIGNATURE: (� DATE: 0 J D .l (f <br /> PROPERTY I BUSINESS OWNER* OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY proof of authorization f0 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 i5 available and at the same time It is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: � � r , PAYMENT <br /> COMMENTS: <br /> �u`�L,� C>WYlsz2 <br /> MAR 0 6 1018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT p <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: ✓�,2 r`vI JU' <br /> Date Service Completed (if already completed): SERVICE CODE: CL - PIE: I h C�L <br /> Fee Amount: Amount Paid 1 S2 �O Payment Date 1 <br /> Payment Type (^o,. lr•l Invoice# Check# Received By:, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />