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Lv <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST L <br /> Ron -2 <br /> OWNER/OPERATOR /F5 <br /> �� � �J � `/ � ECK if BILLING ADDRESS <br /> FACILITY NAME , / � � / ; r� >� '//1/ L <br /> SITE ADORESS <br /> I � nru•. (/j <br /> �-� Street Number I Direction Street Name J Cih� ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) .(�/� �r ���� � <br /> 3 // 0 Street Number ��� Stre etlN name <br /> CITY $ E ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR -_ <br /> REQUESTOR , "� <br /> \/ S'191ue-He2 CHECK If BILLING ADDRESS® <br /> BUSINESS NAME �I 1 !! PHONE# EXT. <br /> HOME or[FAILING ADDRESS / ,L FAX ii <br /> CITY C ly �_\ STATE ZIP Q_57� I <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 18WS. <br /> APPLICANT'S SIGNATUR�E: DATE: <br /> PROPERTY/BUSINESS OWNER y_{/ PER OR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ /T <br /> If APPLICANT!S not til BILLI G 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'he SAN JOAQUIN COUNTY E14VIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided to me or <br /> my representative. 11 <br /> TYPE OF SERVICE REQUESTED: Foe.-' C WI i"a-i <br /> COMMENTS: <br /> AUG <br /> SAE�O ®5 <br /> H -AST UQPf N AUNry <br /> AR rr <br /> ACCEPTED BY: EMPLOYEE#: DATE: /C <br /> ASSIGNED TO: —Ma_ bl4 Vlfy^ -4,,A EMPLOYEE#: DATE: -- <br /> Date Service Completed (if already completed): SERVICE CODE: % PIE: <br /> Fee Amount: �Q -C7j) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />