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SAN JOAQUI.V COUNTY ENVIRONMENTAL HEALTH lit_PARTMENT <br /> SERVICE REQUEST <br /> (FFA <br /> of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ER/OPERATOR CHECK If BILLING ADDRESSTY NAME <br /> SITE ADDRESS %�'n /� <br /> Street Number Direction �`// Street Name/ , Civ Zip Code <br /> HOME Or MAILING ADD ESS (If Different from Site Address) <br /> - Street Number Street N me G <br /> CITY5TATE <br /> Zip- <br /> 95 <br /> PHONE A ExT. APN# LAND USE APPLICATION# <br /> of /2'2 137070 c�'2-- <br /> PHONE#2 ExT• BOS DISTRICT -7LOCATION CODE <br /> ( ) DO a 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORJ r CHECK If BILLING ADORES <br /> BUSINESS NAME /' r-� �/ /�Z�.� PHONEIS# / �I� EXT. <br /> HOME or MAILING ADDRESS /7 FAX# to <br /> CITYC? <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 I have prepared this a cation an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE EDERAL laws. <br /> APPLICANT'S SIGN ��c��Zc _ DATE: ��1'�y <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 Swk <br /> e �•�ovided to me or <br /> my representative. P �CIr l <br /> TYPE OF SERVICE REQUESTED: , RE <br /> CEIVEU <br /> COMMENTS: App 19 Z018 <br /> W Jr fel QUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTt{DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: 4-19 �/V <br /> Date Service Completed (if already completed): SERVICE CODE: 5z� PIE: 1 lPl J <br /> Fee Amount: L}. Amount Paid * i.i.W.;; Payment Date �—k� Iq g <br /> Payment Type ,'� �,,I i ui-_ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />