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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST-# <br /> OWNER/OPERATOR ! �j <br /> ( CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS f^ - ,�( Z <br /> Street Number Direction Street Name CI ,,-rp coae <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 19 L Street Number Street Name <br /> CITY ki STATE ZIP <br /> PHONE#1 rLL� EXT. APN# LAND USE APPLICATION# <br /> ( 26k 06 <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �.pq <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME J PHONE# EIT, <br /> ✓y� /O n <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 5 ,/-c <br /> /c C / ril 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 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. l �i <br /> APPLICANT'S SIGNATURE: nlfej1p dil DATE: d - / O <br /> PROPERTY/BUSINESS OWNER ON VPERATOR I MANAGER ❑ VTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Time <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 same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: -,� I i �, ; CI C G"1 A <br /> COMMENTS: <br /> V'd ) kcM cFOwF r <br /> hFg /y <br /> 4TN R!M OU <br /> H <br /> ACCEPTED BY: `� f � EMPLOYEE#: DATE: 7 RT N <br /> ASSIGNED TO: 'J t EMPLOYEE M DATE: �_ _ J SJ <br /> Date Service Completed (if already pleted): SERVICE CODE: _ PIE: / /J <br /> Fee Amount: j GJ� L L 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 />