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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVI EQUES <br /> T-yu c <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME The <br /> Tq c O S <br /> SITE ADDRESS J Ia' rc,/ C '� e } YI lrfa2oc. <br /> t J <br /> Street Number Direction I I Street Name Ci Zi Code <br /> HOME Or MAILINGRESS (If Different from ite Address) <br /> 3 o i ` ✓' C 7 Street Number Street Name <br /> CITY STATE ZIP <br /> �j �oCK �c r' ojr <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ash 3331 � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S u' oh <br /> , C" CHECK if BILLING ADDRESS <br /> BUSINESS NAMET)I C 1_ ( 1 n � PHONE# EXT. <br /> HOME or MAILING AIDDR SS YJ V FAX# <br /> CITY C STATE ZIP c '1 -2- <br /> 7 C_' <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 laws. �7 <br /> APPLICANT'S SIGNATU; OPERATOR <br /> E: 130,\)AQ DATE: I [� <br /> PROPERTY/BUSINESS OWNER /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, 1, 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 ass I ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same tim ' me or <br /> my representative. RErEIe/ED <br /> TYPE OF SERVICE REQUESTED: H <br /> COMMENTS: <br /> SAENV <br /> ENVIRONMENTAL <br /> HEALTHHEALTH DEPARTMENT <br /> ACCEPTED BY: Ll]� EMPLOYEE#: ) DATE: I <br /> ASSIGNED TO: �Wtn EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /1 P 1 E: ��O 12 <br /> Fee Amount:4 1 Amount Paid o Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />