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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OC) <br /> OWNER/OPERATOR <br /> 1 LA e 1 J 2 CHECK if BILLING ADDRESS <br /> FACILITY NAME —rAC©Sr P41 YZ ` I` )0 <br /> SITE ADDRESS �U l � Ck <br /> Street Number I Direction Street Name c1tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -2-1 <br /> 2—122v/�1���\ <br /> LStreet Number Street Name <br /> CITY STATE CA <br /> tt , r�ZIP �/ <br /> k4�� ((nn `� a EXT. APN# LAND USE APPLICATION# <br /> ! )1 V��'� ll 1 <br /> PHONE#Z EXT. BOS DISTRICT --7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'V I^ ^ I 1 <br /> V CHECK If BILLING ADDRESS <br /> BUSINESS NAME �^N P ' EXT, <br /> (,tJ ) <br /> HOME or MAILING ADDRESS 2FAX# <br /> CITY S / STATE 01) 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 /> 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: �;� 1r1/� DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ti Ile <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locabiduat_the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site ass �� tion <br /> ASI <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It ' , r <br /> my representative. �+ V <br /> TYPE OF SERVICE REQUESTED: I V v ' <br /> COMMENTS: H � q��IN <br /> � CO��y�, <br /> FHT <br /> ACCEPTED BY: (�(� � ,4,� ;) EMPLOYEE#: DATE: L- 20Lr1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: fel 4-111 <br /> Date Service Completed (if already Completed): SERVICE CODE: Do PI E: <br /> Fee Amount: 'J� Amount Paid Payment Date 2 <br /> Payment TypeInvoice# Check# Receiv B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />