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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 't) v I A CE <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME l ✓l l� <br /> SITEADDRESS1 �`� �t\ c -l•`�OC.�\o- <br /> 7� �' Street Number Direction l G/�` Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) j/-�� n <br /> Z(`-7O ��� ` ��� J� Street Number c— Street Name / <br /> CITY \ ` I STATE ZIP <br /> PHONE#1 ^� /v EXT. APN# LAND USE APPLICATION# <br /> (r) ?bs-1 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR <br /> A C CHECK If BILLING ADDRESS <br /> BUSINESS NAME / ,^ I /J PHONE yp� O� ( ExT. <br /> r , Z �j <br /> HOME or MAILING ADDRESS FAX# <br /> 7G AM -FC) <br /> CITY1;1V $TATE ZIP 95-2/0 <br /> N <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 ap Iication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S A E and F R I S. <br /> APPLICANT'S SIGNATU}R�E:: DATE: 5 2 f I <br /> PROPERTY/BUSINESS OWNERS OPERATOR/MANAGER 11OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT/is not the BILLING PARTY,(goof 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS pflD� & me or <br /> my representative. f ENT <br /> TYPE OF SERVICE REQUESTED: rQ(� fl C-] L 'VE <br /> COMMENTS: I`'' h' 14 201 <br /> (� 0-WO�" SAN JOAQUIN COUN <br /> C a�� 90 17 C) y�H DEPAENVIRONMRTTA <br /> Lim <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Z, EMPLOYEE#: DATE: �✓ ai l. ' �/ <br /> Date Service Completed (if already completed): SERVICE CODE: 0 , I PIE: p <br /> Fee Amount: C D�- Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />