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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �J a 5� ,W l s g �Z �5 <br /> OWNER I OPERATOR <br /> rT ^ � t .�// � CHECK If BILLING ADDRESS <br /> FACILITY NAME J� �t9 1 fj <br /> e <br /> SITE ADDRESS / �J'f 1��flAr.19 9 V A, �m G k't�o /v 9JF 2 p`r <br /> r� Street Number Direction Street Name GI Zi Code <br /> Holutur MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam,, <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# _ /� L/D' LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> f ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR / �}_ <br /> T CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> H f h Q _r 9 7 75 2 0 <br /> HOME or MAILING ADDRESS FAX# <br /> ZfI ( ) <br /> CITY ✓Q r� 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 /> also certify that 1 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: �� 7 2417_ <br /> PROPERTY/BUSINESS OWNER it, OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If AppuCANT is not the BiLLJNG 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 assessQr_mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It IS p(p I <br /> my representative. •I J\ ! <br /> TYPE OF SERVICE REQUESTED: �� ff <br /> s nJ AQUIRO N CoU <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I r�,Z J EMPLOYEE#: DATE: vp ' <br /> Date Service Completed (if already completed): SERVICE CODE: a P1 E: <br /> Fee Amount: __r Amount Paid;/_S:2, OD Payment Date T11,3 h <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 �� <br />