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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I cx co 7 r _ S GC C)2-Z <br /> OWNER/0-IPERAT'OR <br /> CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME <br /> SITE ADDRESS U (n '(� v � a <br /> Street Number Direction 1� Street Name Ci Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address)CI <br /> Al r (/Y r. / 1 Street Number Street Name <br /> CITY STATE ZIP <br /> ray S 7 <br /> PHONE#1 EXT APN0.1 (0 12� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT11 LOCATION CODE <br /> l <br /> ( ) OO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 4u Y �/p <br /> I rG� V I (/� Y f-e Ck ( CHECK if BILLING ADDRES <br /> BUSINES AME PHONE# EXT. <br /> I (t cl av2 a 3 �4- ���27 <br /> HOME or MAILING ADDRESS 1 FAX# <br /> CITY —^Yk C STATE`N ZIP i 7, 7 7 <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 AL laws. <br /> APPLICANT'S SIGNATURE:: DATE: <br /> PROPERTY/BUSINESS OWNER El/' <br /> 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 a nt information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the S it , ► bled to me or <br /> my representative. GVV <br /> .... -►- <br /> TYPE OF SERVICE REQUESTED: T l�G� •�A"p t <br /> COMMENTS: L /TC(L ( Y v C/�. [ kt S/� G I O F�` <br /> (/ <br /> s7Pn NMENT ENS <br /> �E ��n <br /> H <br /> ACCEPTED BY: 0 EMPLOYEE#: DATE: ,r� <br /> ASSIGNED TO: EMPLOYEE#: f DATE:Ln C --U <br /> Date Service Completed 4.f already co pleted): SERVICE CODE: L P,E: 1� <br /> Fee Amount: c Amount Paid Payment Date L\ tg <br /> Payment Type Invoice# Check# Received By-. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />