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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> in c� o9� <br /> OWNER/OPERATOR <br /> V1 r—+,, r CHECK if BILLING ADDRESS <br /> FACILITY NAME 0�S L yC L-�� � I <br /> SITE ADDRESS Zy \ � r \ ��� JAv-LA w^ G 52�L <br /> Street Number Direction ` Street Name CI v I \ Zip Code <br /> HOME or MAILING ADDRES (If Different from Site Address) <br /> (G E S f 'A- G1 Street Number Street Name <br /> CITY / STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �( PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ` �? aCl I n 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 ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDE,F L law�r7 <br /> /APPLICANT'S SIGNATURE: v`` — '�' DATE: L- <br /> PROPERTY/BUSINESS OWNER❑ -6PERATOR/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: <br /> COMMENTS: O FIVF� <br /> au 04 <br /> (D o <br /> ACCEPTED BY: � 1� �S EMPLOYEE#: DATE: J"2) _ J <br /> ASSIGNED TO: eS EMPLOYEE#: DATE: /Z I Y <br /> Date Service Completed (if already completed): `2— �., i b SERVICE CODE: P I E: C 3 <br /> Fee Amount: ` G 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 />