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SAN JOAQUI" `1OUNTY ENVIRONMENTAL HEALTI DEPARTMENT <br /> SERVICE REQUEST SV1,06 5 g 3`1 S <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> a <br /> FACILITY NAME ' <br /> SITE ADDRESS 1Q �(1•} S� ` �C� 1�} G�`D <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONF� EXT. <br /> IS <br /> HOME or MAILING ADDRESS I . c- FAX# <br /> 7c CID �aJ r 1) J-4lc 3 - '�9'99 <br /> CITY cD+o Lv--bo n C S 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ([;? /'I/2Ir( r—*�C DATE: s��'�/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER LCJi OTH R VTHORIZED 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ���� �' -PAYMENT <br /> COMMENTS: <br /> MAY 2 8 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BL EMPLOYEE#: / DATE: <br /> ASSIGNED TO: �j C �(J��' EMPLOYEE M !=� Iq DATE: <br /> _ <br /> Date Service Completed 0already coma d): SERVICE CODE: f PIE: <br /> j <br /> Fee Amount: C Amount Paid 0-xe? c Payment Date " g <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />