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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .5400 7 I ZSg <br /> OWNER/OPERATOR M "i I ,/ <br /> I/V CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS C— cI G 4 I -F <br /> 5[reec rvumber Direction I Street Name —City ZiD Code <br /> HOME Or MAIL[ DRESS (tf Different from Site Address) -_SN( i C / Street Number Street Name <br /> CITY T 9 14C — STATE C 11 ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# rj <br /> 873 1-7 i 16 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /✓1��'I�( �4 t;2 51-7 DATE: <br /> PROPERTY/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 /> to 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. <br /> TYPE OF SERVICE REQUESTED: � 'yIS-cU t E1V <br /> COMMENTS: '- <br /> �GCDnnJCiXB -2i� : 3 �7Zg �, JAN 0520,1 <br /> SAN JOAQU1t'y CO <br /> HE "H p�P ENTALN <br /> ARTMEN <br /> ACCEPTED BY: yin n n� EMPLOYEE#: DATE: <br /> ASSIGNED TO: 't / / EMPLOYEE#: DATE: <br /> Date Service Completed (if al ady completed): SERVICE CODE: ' PI E: 160 ' <br /> Fee Amount: ' ? D Amount Pai 3d Orj Payment Date S <br /> Payment Type /�<41 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />