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SAN JOA IN COUNTY ENVIRONMENTAL HEALT"DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9/2 06-7? +-39 <br /> OWNER/OPERATOR <br /> ,^^I I� � C� CHECK If BILLING ADDRESS <br /> FACILITY NAME i n ) Ce <br /> J C—rQo��,n <br /> SITE ADDRESS (/ CCr joeV f-er- <br /> 3 Street Number Direction 1 Street Name c Ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /as- <br /> s 1 �� �a /I f <br /> / ( Street Number Street Name <br /> CITYS ` / / '1_ STATA/� 4I�a <br /> PHONE#1 �ryLK�" �� EXT. APN# LAND USE APPLICATION# <br /> Z3 4 <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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 TATE and FEDERAL WS. <br /> APPLICANT'S SIGNATURE: ' A DATE: <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 provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �� ) �i[� � �i�a!✓1 !�� <br /> COMMENTS: <br /> jc� <br /> SAIV <br /> H N ORO Ul�DU TY <br /> ALT ` A1R9 N <br /> ACCEPTED BY: i�M,fj9) <br /> EMPLOYEE DATE: <r�RTTA` <br /> 1 ��N Q'�©'? 1t J2 a I-7 ' t <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> (�J•a <br /> Date Service Completed (if alr ady completed): SERVICE CODE: PIE• <br /> Fee Amount: f ``o Amount Pait 'j�,6� Payment Date �j 2� 1 <br /> Payment Type Invoice# Check# ReceWed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />