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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �C0 gmI _f'` � <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> z` LK �o anrJS <br /> FACILITY NAME I I <br /> pv-\L K <br /> SITE ADDRESSr ' /> }IGC 1 �nG <br /> 2 Street Number DirecS tion I 0 1 Street Name Ci Zi Codee <br /> E Or MAILING ADDRESS/(if Different from/Site Address) <br /> IG t V Street Number Street Name <br /> CITY STATE ZIP <br /> hoc t� C A . �l 45 raO0 <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> -� <br /> PHONE#2 EXT. BOS DISTRICT 1 LOCATION C7DE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> \ �` r.Q �^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME TE � \C \,tel/,J\ �+\ PHONE# �� � EXT. <br /> HOME Or MAILING ADDRESS C� Y i FAX# <br /> CITY b` ^ 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, ST E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <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 assess ent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pl �pF Deo <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: c+1 py) , <br /> COMMENTS: IYUV SAN JO 21 2011 <br /> �_'Y 11'�G� C� d v%►�1l� NEF NV/R ON COON7 <br /> CTy OY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: ' / —7 <br /> Date Service Completed (if already completed): SERVICE CODE: U P/E: 6 7J <br /> Fee Amount: U 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 />