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'R SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> }ACEI NAME\ C--) <br /> SITE ADDRESS (> <br /> Street Number Directionl �lStf d4 t�art1€` <br /> HOME 0 MA LING ADDRESS_fif Different rom Site <br /> Address) <br /> C <br /> C ,� Street Number Street Name <br /> TSTA+EIP �O <br /> Inc �� <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (y C)5-Llo <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE UESTOR <br /> 1' y-W \ 1 2—/,/'�4 I-l ) CHECK If BILLING ADDRESS <br /> AME l <br /> Bu S1 NAME 1 1 I PHONE EXT. <br /> HOM[(- r ADTSS ILING ADSS FAX# <br /> � �� ) <br /> CITY TCl /Cyo 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 /> ACOUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> PPLICANT'S SIGNATURE: �yIcs2f' h,-_''fir, .',, DATE: <br /> PROPERTY I BUSINESS OWNER <br /> 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 assessment information <br /> t0 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. n <br /> TYPE OF SERVICE REQUESTED: -�(j c _e C� - &7. <br /> COMMENTS: O` D <br /> C �Ja o tit 4E'J04Q1JJ 32 �6 <br /> gtUO EAXI�T- NAY <br /> Ml_ , <br /> ACCEPTED BY: ' EMPLOYEE#: DATE: /6 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �1 J PIE: 14% p <br /> Fee Amount: C 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 />