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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Types or Property FACILITY ID# SERVICE REQUEST# <br /> i�7 <br /> %�, �on -5eOO5,53-72&_ <br /> OWNER I OPE TOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Y�/�,/t ,(� I <br /> SITE ADDRESS )bc � <br /> Street Number i -tion Street Name Ci Zi ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHO #1 i) EXT APN# - LAND USE APPLICATION# <br /> 7 ' <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> y�Af CHECK if BILLING ADDRESS <br /> BUSINESS N,w .. � � / C (j ) PHON # EXT. <br /> HOME Or MAILING ADDRESS <br /> CITY 1\J1v1 STATE IP <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. c <br /> APPLICANT'S SIGNATURE: 1 u'- DATE:,, C 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE ❑ OTHER AUTHORIZED AGEN \ IC.I It�( ����( 1(k <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is requir d 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: U37 <br /> COMMENTS: plxt-SC? ��� � �,EC�)1�P f�` S`\I J -A' I vrc -/ �F�� T� <br /> Q 1 ►�/ED <br /> SEP - 5 2008 <br /> 8*4 JOAQUIN COUNTY <br /> E <br /> ACCEPTED BY: EMPLOYEE#: d H A <br /> ASSIGNED TO: EMPLOYEE#: v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: l rJ s <br /> Fee Amount: C Amount Paid X _ Payment Date <br /> Payment Type Invoice# Check# :. % ." ( " __ Received By: N - <br /> - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />