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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SIS . '�C7 93 — <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> IT DjES$ D Street Number Direction �L STF N . <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. API# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATI CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'Y J� <br /> O k v) CHECK if BILLING ADDRESS O <br /> BUSINESS NAME 1 L 1� C ✓ / PHONE# <br /> Ll XT <br /> U J J 1, 2c �-3`�— <br /> HOME Or MAILING 7DRESS ,n t _ I„ / �' � FAX# <br /> 10 <br /> `i/llJJ1 Y t Ivf�JifJvSJ ( ) <br /> CITY In , O� STATEC ZIP C�`� `? <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. 4 <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance vd II SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: S,P,� (,t �, t��J DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ de- <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required y Q RI <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the� 4lpcate�a the abo� <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmentaT� me rmation�� <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same t p�v1�0 me or O <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Pour�l -,M rev i ext) f-c�I— <br /> ACCEPTED BY: EMPLOYEE#: DATE: , <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5-,�I:3 PIE: 2(,p <br /> Fee Amount: `3(,t Amount Paid -3 Payment Date <br /> Payment Type Invoice# Check# 35�`�c{ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />