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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 <br /> CHECK if BILLING ADDRESS <br /> ass � <br /> FACILITY NAME W`N <br /> SITE ADDRESS Sri-`STN �S•��b� <br /> 2H-{ 0 Street Number Direction \ Street Na Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> SirJ' Street Number Street Name <br /> CITY STATE IP <br /> N GL`A C 3 I <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> I \-A Is L S <br /> BUSINESS NAME L `I( i PH ,# �� (2 EXT. <br /> HOME or MAILING ADDRESS,, I FAX# <br /> '271 1," J ` ( ) <br /> CITY r $cTf, a�33 W <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 /> I 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. <br /> APPLICANT'S SIGNATURE: `-' d�1 V Ll l l ri <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 same time It IS to me or <br /> my representative. E' <br /> TYPE OF SERVICE REQUESTED: vwd �dliuu q AWT)/x, I <br /> COMMENTS: �A.�(•A <br /> SAN,/0.4Q <br /> �A•.JOp ©5 �O�J <br /> u/N CO <br /> HPALNI i f�EPq <br /> FNT <br /> ACCEPTED BY: VU EMPLOYEE M DATE: <br /> ASSIGNED TO: , • `� w,�,j 1�1 EMPLOYEE#: DATE: <br /> Date Service Completed (Already completed): SERVICE CODE: D4? 1 PIE: <br /> Fee Amount: Amount Paic,. %C �/ Payment Date <br /> Payment Type �. Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />