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SAN JOAQVIty COUNTY ENVIRONMENTAL HEALTH L r-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �23c�Z I `>V DM20 � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 LA J�„ _•A Y� (0 m G1y D S M�0O <br /> SITE ADDRESS D � Cm1%I ��iIQ i <br /> . G <br /> 75- <br /> Street Number Direction Street Name Ci co o <br /> Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ��2 S� �a l�Gl /L <br /> Street Number J Street Nam¢ j�`�� <br /> CITY � /( STATE CA ZIP <br /> V�0 11 ZlC7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ �1i CHECK if BILLING ADDRESS <br /> BUSINESS NAMEutLi►N (� �C vo PON # EXT. <br /> ,vt l 7 - <br /> HOME or MAILING ADDRESSI � Fev-„ —o > Fax# <br /> CITY G���� ^ STATE h/Y 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, Standardsf STATE and FEDERlaws. <br /> 0 r <br /> APPLICANT'S SIGNATURE: t�`7 (� kc i DATE: 1, I 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT iS t 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 provided to me or <br /> my representative. +_ AP <br /> TYPE OF SERVICE REQUESTED: eV <br /> COMMENTS: °�► <br /> y�4T R 71V CO <br /> OFAq�,yT� <br /> ACCEPTED BY: 1 •`� EMPLOYEE#: DATE: -7 <br /> ASSIGNED TO: f EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ln� <br /> Fee Amount: (� Amount Paid'✓ ;'�� ) Payment Date <br /> Payment Type "1 .. Invoice# Check# Rece ved B . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />