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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH •ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERA.TQR ^ (/ CHECK if BILLING ADDRESS <br /> FACILITY NAME Y n <br /> SITE ADDRESS I /�LS /� �'r ESDI <br /> Street Number Direction `� ���` I� iet'i•N �Aw �� ��r Zi Code <br /> HOME Or_M <br /> � NG�A!,DDRES IfDilerent from Site Adess)pirI <br /> Street Number Street Name <br /> CITY �)' STATE ZIP <br /> PHONE#1 EXT. qpN# LAND USE APPLICATIONCJ#` <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST <br /> r <br /> o ` O p—z CHECK if BILLING ADDRESS <br /> BUSINESS NAME '/: r/l�� HONE# EXT. <br /> cd <br /> HOME or MAILINGDDR ( FAX# <br /> CL{� L nc ) <br /> CITY O ' I'. J 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 I have prepared thisapp LGation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER IQ 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: c^ e41 I d t—;� Ij eiv <br /> COMMENTS: <br /> CVIa i1Cl-e-. DEC <br /> 1 c� 2 7 201 <br /> L,I c, S EiWIRONIN COUN <br /> HEALTH DE gRTTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE:)7--,2- 7- /7 <br /> Lk <br /> ASSIGNED TO: i (J j Z,_ EMPLOYEE#: DATE: /2- Z -7 J 7 <br /> Date Service Completed (if already Completed): SERVICE CODE: /^J PIE: lb v <br /> Fee Amount: jZL Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />