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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTOIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pro�rt FACILITY ID# SERVICE REQUEST#, <br /> 1 OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> [A bei �Y <br /> ( FACILITY NAME <" <br /> SITE -T <br /> -DDRESS <br /> --19 �� �/ !; � <br /> �y") S' Stre t Number Direction , 1 - St eet Name � C•uCJi ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> v <br /> Street Number Street Name <br /> ICITY /STATE ZIP <br /> CC / 3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> �oILI' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> 4c'A'-') CHECK If BILLING ADDRESS <br /> BUSINESS NAME �Y PH NE# EXT. <br /> s (cvLt'- 3�i1 �- <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 /> I also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY f BUSINESS OWNER OPE TOR/MANAGER OTHER AUTHORIZED AGENT ❑ M <br /> If APPLICANT isnot the BILLING PARTY,proof 6fauthorization 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 a5 soon as It IS available and at the Same time It Ispro\ided to me or <br /> my representative. � <br /> TYPE OF SERVICE REQUESTED: j ncx V 0 11 t C OCT <br /> COMMENTS: <br /> "�9N t„ D���t <br /> FN°Aov,N S <br /> yE41.ThI Oc qR�q�HT1' <br /> MFM <br /> ACCEPTED BY: EMPLOYEE#: DATE: `C _/ <br /> ASSIGNED TO: -Z_ EMPLOYEE#: DATE:tA <br /> _ <br /> Date Service Completed (if already completed): SERVICE CODE: i�, J PIE: L) <br /> Fee Amount: ' \ Amount Paie A Payment Date <br /> Payment Type Invoice# Check# t . Receiv d By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />