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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (� -021 FA 06-7� 791 <br /> OWNER/OPERATOR <br /> n�/ � CHECK If BILLING ADDRESS El <br /> JFACILITY NAME I�'lt/;I i I �-0 <br /> SITE ADDRESS <br /> DStreet Number I Direction <br /> 11M <br /> M =Aent from Site Address) Street Number Stre Le <br /> CITY STATE ZIP O <br /> PHONE Ill EXT. APN# LAND USE APPLICATION# <br /> W)o ??- <br /> PHONE#2 l n EXT. BOS DISTRICT LOCATION CODE <br /> ) L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQEST R <br /> � O CHECK If BILLING ADDRESS <br /> BUST ES NAM PHONE# EXT. <br /> uoMa)S Z(, ein 64g2) <br /> HO E r M#iLING RE FAX# <br /> CITY 1 STAT 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 1 have preparedthis pl' ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Z2,ZI 7 <br /> PROPERTY/BUSINESS OWNER 11 ' OPERATOR/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 at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assea t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the sal *6 'Ided to me or <br /> my representative. I-L- RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN jOAQUIN COUNTY <br /> civoCle G C,-V,) � ENVIRONMENTAL <br /> HEA-TM DEPARTMENT <br /> ACCEPTED BY: <-�r�' EMPLOYEE M DATE: <br /> ASSIGNED TO: r- Z EMPLOYEE M DATE: 2 . <br /> Date Service Completed (if already Completed): SERVICE CODE: v^ PIE: <br /> 1 acri <br /> Fee Amount: i Amount Paid Cb Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />