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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -hoc �C� 1b9' 0C) ?gogq <br /> OWNER/OPERATOR ` <br /> ZV /A j��I Q CHECK if BILLING ADDRES5a <br /> FACILITY NAME � �/ � � ' <br /> SITE ADDRESS Z� �1 ^ ���tt I,�/v'��(��-/}'`�-^�, �'j��/ <br /> �t Number Direct V o l d I t Name K)cx q S Ci q Zi Code <br /> HOME or MAILING ADDRESS (if Different rom Site Address) <br /> V tvii Street Number Street Name <br /> CITY '�Tocfvl tfv STATE i ^ ZIP cl �(^ <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# L <br /> 001) �;D-Ir - 12CP"L )co a� <br /> PHONE#2 EXT. BOS DISTR T LOCATION CODE <br /> 0cJ) (DCOZ - �l�l C)t3� cig <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Rvv—A A,Gt ,�/I\ 11 p�,l A CHECK if BILLING ADDRES <br /> BUSINESS NAME To�T �1 �"`T �tV v v, 1 ✓� Co PHONE#� _ I EXT. <br /> HOME or MAILING ADDRESS �"� FAX# <br /> Avic <br /> CITY L'—tcc STATE (�- ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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, Standa STATE an AL laws. <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: vED <br /> COMMENTS: <br /> SVR 2ot <br /> V <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �p n n, �q EMPLOYEE#: DATE: ,r_ 2— -/ <br /> Date Service Completed (if already completed): SERVICE CODE: 23 PIE: <br /> Fee Amount: ,� Amount Paid `ts�o Payment Date 2f, <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />