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vv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERV CE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS C) T�� O,` l2� <br /> / /Street Number Direction V Street Name Ci ZiJCode� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /�JO 76 <br /> Street Number tk"' r Street NaMe � <br /> CITY r�n ^ j STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# `` o <br /> ( ) XCep - 11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J CHECK if BILLING ADDRESS <br /> 1 �,�1� sc�'1►2C�, <br /> BUSINESS NAME /� }s� PHONE# EXT.a� -ao t <br /> HOME or MAILING ADDRESS ^ I FAX# <br /> CITY C oC STATE ZIP)67L7(O <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 F. RAL laws. <br /> APPLICANT'S SIGNATURE: DATE:_ 611 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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 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 providP� me or <br /> my representative. �V <br /> TYPE OF SERVICE REQUESTED: V I C <br /> COMMENTS: �A <br /> Q 20 <br /> UZ <br /> hI pF MFH COU <br /> ACCEPTED BY: �.`� EMPLOYEE#: DATE: 2D/ <br /> ASSIGNED TO: ��— EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: �'— P/E' a <br /> Fee Amount: 0 Amount P (OO�(U D Payment Date (1-/X// <br /> ` ` <br /> 67 <br /> Payment TypeC J� Invoice# Check# ,Lf Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />