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SAN JOAQU..,4 COUNTY ENVIRONMENTAL HEALTH UtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S ; �C C 1�1c�b� fog <br /> OWNER/OPERATOR (� <br /> P1� 0- cj�- \11/� I / CHECK If BILLINGADDRESS� <br /> FACILITY NAME� /Q �v�\ PI`C1F /'l <br /> S TE ADDRESS ` C' I^ _ I C7 <br /> 1 Street Number -Direction `�e /\A <br /> 1 1 Street Name " oL� -�" \ ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 3 c7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �t^� 6T <br /> L 1/ — CHECK if BILLING ADDRESS <br /> / J )J I ) �l t v l"\ <br /> BUSINESS NAME PHONE# EXT. <br /> 5, /l C � <br /> HOME Or MAILING ADDRES/S� FAX# <br /> Ig 1 S� L V ( ) <br /> CITY C. t E STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property c;;.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: /Yl+/9 ``cri— k' ✓ DATE: <br /> PROPERTY/BUSINESS OWNER-0 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the same time It IS prov ! me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Do " �� h <br /> COMMENTS: r'�/v i• V <br /> �I ?D� <br /> G C�� R NI N CSV <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Y J EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: P/E: , <br /> Fee Amount: ; Amount PafJ-P Payment Date <br /> Payment TypeInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />