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SAN JOAt..UIN COUNTY ENVIRONMENTAL HEALTh )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WWW pD 1EI3 Y <br /> OWNER/OPERATOR <br /> -'' Ce � f)Z CHECK if BILLING ADDRESSEL <br /> FACILITY NAME <br /> SITE ADDRESS n <br /> 23. N tuber Direction r Stree�me <br /> HOME Or MAILING ADDRESS (If Different from Site <br /> Address) <br /> / Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME i PHONE# EXT. <br /> HOME or MAILING ADDRESS ' FAX# <br /> CITY 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. <br /> APPLICANT'S SIGNATURE: C! �C-'SdS S�?►'I )>1 ��DATE: d ' 12? /0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to 51911 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: 1 o Od �/ o l O f iffe"On REC En;�9�1 <br /> COMMENTS: <br /> NOV 2 l 2�iI <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /l/// a I O EMPLOYEE#: DATE: I� 1 <br /> ASSIGNED TO: f VVI ` /7 EMPLOYEE M DATE: f t <br /> Date Service Completed (If already completed): VL SERVICE CODE: / 'J 7 Pll E: <br /> Fee Amount: 5 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 />