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SAN JOAQL,t.v COUNTY ENVIRONMENTAL HEALTH L,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR � ' <br /> M/��/-1e-1 , l` CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME �1 / <br /> SI �J�- I-� 's CF CSF <br /> SITE ADDRE S <br /> S- C tj R PC-A) %OC��o� <br /> Street Number I Direction Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> j 5 S - I? r/-C/-1(M S / Street Number Street Name <br /> CITY r ' STATE ZIP Cj r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> U09 406 208S- <br /> PHONE#2 �� �� �_ IT, BOS DISTRICT LOCATION CODE <br /> EI1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /T n� (/G I `^ / _ CHECK if BILLING ADDRESS <br /> BUSINESS NAME ' PHONE# EXT. <br /> S f ri C(N S 1-4 z cz /-* <br /> HOME or MAILING ADDRESS FAX# <br /> CITYI—C-)C1.2/ON STATE(,�,",q 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 /> �7 <br /> APPLICANT'S SIGNATURE: DATE: ZZO <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 provi t6l e or <br /> my representative. �1 M <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> h�CM'/RON�NCO� <br /> THpF M�NT�G <br /> ACCEPTED BY: wk o(/I v n � EMPLOYEE#: DATE: -30 0 <br /> ASSIGNED TO: n V�v�"�'��n J EMPLOYEE M DATE: l 3p ( <br /> Date Service Completed (if already completed): SERVICE CODE: O I PIE: 0 <br /> Fee Amount: I 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 />