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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - � � Seo �0112-+ <br /> OWNER/OPERATOR En cn <br /> O C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Y <br /> SITE ADDRESS iF Qr <br /> 2-�� I 0o Street Number Direction Street Na Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) G f'ak �avr� AV(� <br /> IQ Ir Street Number Street Name <br /> CITY �� STATE ZIP <br /> 1�5O`b <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Raman& G rce AJA_ CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> - G . ✓e ( ) <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 /> 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: ,�I <br /> r DATE: l�f d O/I Cl <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG ❑ 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 assessor t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is protQ me or <br /> my representative. � <br /> TYPE OF SERVICE REQUESTED: ,V <br /> COMMENTS: ✓o 0 D '701S <br /> H��Rp Ui c <br /> o pMFH q�H� <br /> 'gRTM�HT <br /> ACCEPTED BY: \ EMPLOYEE#: 0 0 DATE: <br /> ASSIGNED TO: viapirEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I <br /> Fee Amount: 199 0 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 />