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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> -,�� <br /> OWNER/OPEERAAT.OR' 1 /� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME V`_ <br /> SITE ADDRESS Vl �l ;" -('j C r2_ (LD 2�Z <br /> IJ0 W• Street Number Direction Street Name Cit Zi Code <br /> HoloOr MAILING ADDRESS ( Different from Site Address) <br /> '1/ Street Number Street Name <br /> CITYi $TAi�E <br /> I� ZIPC <br /> WD 2� <br /> PHONE#1 EXT. APN# LAND USE APPLICATI # <br /> (161) G-3c( - iqq� C)2_f_)-o2 _ po <br /> PHONE#2 EXT. BOS DISTRICT LOCATION D <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �-f'�'` <br /> \t Ov CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> LQCM� ( ) <br /> CITY (n I STA ZIP 01 <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. 1) <br /> APPLICANT'S SIGNATURE: DATE: 12-1 12-019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT M Ty-o.;,e-c-+ �'tCLKGz y` <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 /> to 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: <br /> COMMENTS: <br /> MAY <br /> 1 419 <br /> NPA, ViRO UI N CC 1JN 7. <br /> ACCEPTED BY: EMPLOYEE#: DATE:14 <br /> O P L <br /> T ANT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7/ P I E: o-Z_ <br /> Fee Amount: d1 Amount Pa D� Payment Date <br /> Payment Type Invoice# Check# 32 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />