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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# %66TT�f <br /> QUEST# <br /> ��14 m r - n, , m <br /> OWNER/OPERATOR n <br /> 1114fa CHECK If BILLING ADDRESS <br /> FACILITY NAME ` <br /> SITE ADDRESSLI ra I /— <br /> Street Number Direction trees Name Cit Zi Code <br /> HOME Or <br /> f fMAILING ADDRESS (If Different from Site Address) <br /> i 7t�j) fl Street Number / lQ <br /> Street Name <br /> CITY STATE ZIP <br /> T. 70 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> OzY 64f 1 — ( 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR sl I ' ^ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /�I J//yy� }jRE / 9f_ <br /> /� � 1 PHOONE# o � — I � EXT. <br /> Jo <br /> HOME or MAILING ADDRESS t/( I/7 (- r-/ FAX# <br /> CITY ,/� X470 1 1 STATE //1 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 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. <br /> APPLICANT'S SIGNATURE: 0 11,/ r'V% . '4 ('h Cf�j�m c4 DATE: <br /> PROPERTY I BUSINESS OWNER❑ 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 1i gr <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: QG S " 601 ' 14�b <br /> COMMENTS: �S <br /> ✓o oc <br /> 42 <br /> Fp Fiy Uig <br /> ACCEPTED BY: TO <br /> LA <br /> I ^m EMPLOYEE#: ) DATE: �/1 / <br /> ASSIGNED TO: `1 EMPLOYEE#: DATE: C/r/ <br /> Date Service Completed (if already completed): SERVICE CODE: D& P I E: <br /> Fee Amount: 2' OL Amount PallS�,U Payment Date 7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />