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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH L,,LPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TY_ Ud� 3 () P( o 3-� <br /> OWNER/OPERATOR /� <br /> J_t A 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME f J/`�l nw C L <br /> SITE ADDRESS Z O C �` �v ^� / ���� / Zr <br /> Street Number Direction /rZtreet ame `J citv7 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> '}it <br /> ! Street Number Street Name <br /> CI / STATE ZIP <br /> / 2-3s 2 <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> c7c" 3o--U <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> A �� <br /> BUSINESS NAME y^% � ,, ,, O PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> v c :- c ) <br /> CITY C J�/J ,. : /) STATE ZIP C 7� <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 erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Titre <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: V21 Uff U <br /> COMMENTS: <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 1 4 C, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/ <br /> Fee Amount: .5�) U0 I <br /> Amount Paid Payment Date e-. / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />