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SAN JOR,-,JIN COUNTY ENVIRONMENTAL HEALI r. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#,—, <br /> OWNED/OPERATOR / <br /> r � V L CHECK If BILLING ADDRESS E] <br /> FACILITY NA E <br /> lJ <br /> SITE ADDRESS„, �� <br /> ------._ber Direction - treetNameV 1� city <br /> HOME or MAILING ADDRESS (IfIDifferent from Site AdMMI ,Z G L�.{� �-f— <br /> s <br /> Street Number treet Name <br /> CITY STATE ZIP <br /> cC CG.L• 2 S" <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (f6� ) y-�o e/1! 7 I <br /> r <br /> ONE j2 �� EXT, BOS DIS T I LOCATION CODE <br /> e(ICONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> , �� CHECK If BILLING ADDRESS <br /> BUSINESS AME PHONE# EXT. <br /> (All) LnZg 72 <br /> OME or AILING AD RES 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 /> APPLICANTS SIGNATURE: yy <br /> ' ,j., <yS t /�G!/S 44 DATE: Z' ��� <br /> PROPERTY/BUSINESS OWNER b OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT'is not 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 a he above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment IAofVj N� <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is prov / <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Q <br /> COMMENTS: $AIV J <br /> EA �O UIN NTA Nry <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: I - 1 -7 <br /> ASSIGNED TO: r/� (j n EMPLOYEE#: DATE: I Z- • � <br /> Date Service Completed (iiff alr�eaddy completed): SERVICE CODE: P/E: <br /> L' <br /> Fee Amount: I G, �� Amount PaIdP ��7� Payment Date <br /> Payment Type / Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />