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4-� 3o <br /> SAN JOAQU... i3OUNTY ENVIRONMENTAL HEALTH L_?ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW R/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS � � /r, /'� � `(�/�✓' ��—/�7� <br /> S et m r DI coon �J Street Name Ci v 2I 6o7e <br /> 0ME or IN S If iff-- trgm Site ddress) <br /> (]�� •l{— Street Number Street Name <br /> CITY ` <br /> . STATE /� 0 ZIP <br /> / Exr. APN# LAND USEAPPLICATION# <br /> PHONE#i EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f�� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME N y EXT. <br /> ao <br /> r ING D RE 1 i fAX# <br /> C ky STATE /„ ZIP n <br /> Y� v <br /> BIL ING' ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authori d 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: j,-�j_ DAA —<4 4 11C) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 proV ��Ie Or <br /> my representative. VPAN <br /> //A/►� a. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ` 1)'(-I'; <br /> SAN I! <br /> HE C -1V/Q ILS� ry <br /> � Ty <br /> PART ME T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Cl EMPLOYEE#: DATE:7 <br /> Date Service Completed (if alre dy completed): SERVICE CODE: P/E: <br /> i <br /> Fee Amount: Amount PaidL�� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />