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SAN JOAQLjt.V COUNTY ENVIRONMENTAL HEALTH UtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4�' 03—&D�S 0 <br /> OWNER/OPER + <br /> i ` , � , � O ` •'I, � CHECK If BILLING ADDRESS <br /> FACILITY NAME C©- S <br /> W)�t r► t) c,a 5 1 ✓l Ao efts-e- <br /> SIT30 Street <br /> '.> Y'��Yt i 3 k }j t✓�'�✓✓t 4j S�}o <br /> O Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADRESS(If Different from Site Address) <br /> ) (j n <br /> Street Number u Street Name <br /> CITY !' 4-V <br /> $TATE ZIP(� 6 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (ZLq) 0 3 - R's( l <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <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 applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATE nd FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: G1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 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. MENT <br /> TYPE OF SERVICE REQUESTED: � 1 nA c v-&v— <br /> COMMENTS: \i �1 9 <br /> Pv ( ,�r � Yr l <br /> •p 3 � � 1 �-+ 1 r � "'1 ,�!{ f'� � 219 V <br /> V ✓ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: yy v EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: c�;Z PIE: <br /> Fee Amount: (� t!� 1� Amount Paid Z —-.! _ Payment Date <br /> Payment Type Invoice# Gheck# :�) �- i �� -7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />