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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �1� 5�- C a ::2 -1---ip 000 (099N 5(Z o0--7-F8252 <br /> WNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> i <br /> FACILITY NAME <br /> Z <br /> SITE ADDRESS 24�- <br /> Z3 Street Number Direction d '6fteet Name 17%9- <br /> e <br /> QME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CAT STATE ZIP <br /> -,s Ca <br /> PHONE# EXT. APN# LAND USE APPLICATION# <br /> PH NE#2 EXT. BOS DISTRICT2 LOCATION CODE <br /> ( ) C0J <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> O CHECK If BILLING ADDRESS 13 <br /> BUSINESS NAfAIE PHONE# EXT. <br /> ,64G <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <br /> BILLING ACKNO LEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> 1*1 <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 /> G �7 <br /> APPLICANT'S SIGNATURE: DATE:J <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titte <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 provi me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTSL-iG <br /> H Eiy�OR�UlN C0U <br /> �CmO��MFN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: U� EMPLOYEE#: DATE: 3 .L l;F <br /> Date Service Completed (if already completed): SERVICE CODE: C)LO 1 P/E: MZ <br /> Fee Amount: c Amount Pat 77]7Payment Date �L C <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />