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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> MAth <br /> FACILITY NAME <br /> SITES ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILMGG�ADDRESS If differentt fromSiteAddress) 4W3y 7� <br /> r %✓G !�Ki�r Street Number �C/ W Street Name <br /> CITY C 4.� TATE �zzC.3 <br /> PHONE#1 7 EXT. APA[# LAND USE APPLICATION#`J <br /> PHONE#2 EXT. EOS DISTRICT LOCATION CODE <br /> CONTWiC OR SERVICE REQUESTOR <br /> REQUES3 <br /> /�� �I }� CHECK if BILLING ADDRESS® <br /> BUSINESS NAME //G `�[) � ExT. <br /> �' ! �� 7� t l PHONE# � <br /> Hor�lEorM�L1NGA�ADRFESS � FAx#1-94U2 ) <br /> CITYAo; 16 n[�' STATE <br /> BILLINGLACKNO1i'IILEDGEMENM 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 an FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: ,�1l11 _ <br /> PROPERTY BUSINESS OWNER. OPER TOR 1 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 avaiiable and at the same time it is provided to me or <br /> my representative. IN I <br /> TYPE of SERVICE REQUESTED: <br /> COMMENTS: a w <br /> MAR442010 <br /> SAN JOAQUIN COUNTY <br /> ENVtROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3 <br /> ASSIGNED TO: �`� EMPLOYEE#: DATE: 7Nho <br /> Date Service Completed (if already completed): SI_RVICE CODE: � P I E: �Z <br /> Fee Amount- Amount Paid 2. > , C9 [J Payment Date <br /> Payment Type G Invoice# Check# f f Cjt$ Received By: � <br /> t / <br /> EHD 48-02-025 SR FORD(Golden Rod) <br /> 07/17/08 <br />