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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> New Z . F. R. SiZ�z,�I p0-7 <br /> OWNER/OPERATOR <br /> eO r.,^ _s CHECK if BILLING ADDRESS <br /> FACILITY NAME / V ` <br /> SITE ADDRESS <br /> 1 1J Street Number Direction Street Name city Zi Code <br /> HOME or MAILING <br /> �Si <br /> G ADDRESS (If Different from Site Address) I 'a C'./1 �Z".1 / V, <br /> Street Number �'T' Street Name l• <br /> CITY t>� STAIE� ZIP ^ ; <br /> 1C 1 ((�� r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (24) sos 9 C( 3 '� <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) C 3 �I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR1 <br /> �t n w'T d1 /�DY.✓.t� CHECK if BILLING ADDRESS <br /> BUSINESS NAME N V PHONE# „ EXT. <br /> HOME or MAILING ADDRESS IJ' V). x^-33 FAX# <br /> & a(J�• J ( ) <br /> CITY '1. o^ STATE n 4 ZIP q J �? / /_ <br /> BILLING ACKNOWL DGEMENT: 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 appy ation and thew k to be p ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STA E and ED A laws. <br /> ' 9 APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER LW PERATOR/MANAGER ❑ THER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7'trl e <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 i <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provld <br /> my representative. A /♦hi(�, <br /> TYPE OF SERVICE REQUESTED: S Ati n �® <br /> COMMENTS: V JOq �Q <br /> tiR p�/N c0 <br /> yD`e�NTq Nry <br /> M T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ?� <br /> Fee Amount: Amount Pai 6� Payment Date <br /> Payment Type ` f Invoice# Check# ( Reo6ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />