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r <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER IOPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> , <br /> SITE ADDRESS c <br /> C S 'mav <br /> Street Number Direction Street Name Cit 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# i LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATIOJV9ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> f^i(�,G�i � CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> �O r� (tel ) 3�-J '77 <br /> HOME Or MAILING ADDRESS FAX# <br /> C)-z— `A ^ ( ) <br /> CITY STATE 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR/M NAGER ❑ OTHER AUTHORIZED AGENT El S I <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: <br /> COMMENTS: RE(JE'VED <br /> T <br /> SEP I 1 2008 <br /> ,,rte SAE JOAQUIN COU <br /> ACCEPTED BY: C V.e✓C EMPLOYEE#: P��- DATE: P <br /> I <br /> ASSIGNED TO: �� , EMPLOYEE#: C) 3 DATE: R 1 7,-f p <br /> Date Service Com leted (if already completed): SERVICE CODE: �zZ- P I : p ' <br /> Fee Amount: 0 -j Amount Paid I o r Payment Date l2" U <br /> Payment Type ✓ Invoice# Check# 2 �2 S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />