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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# G�EORVOI�REQ�IES <br /> OWNER 1 OPERATOR <br /> C C V t t A Al CHECK if BILLING ADDRESS <br /> FACILITY NAME V <br /> Ste,✓ 7 ' � T/��/�j�C�'n/ T <br /> SITE ADDRESS � u <br /> Slreet Number Direction /`d� / Street Name) �C Zip Code <br /> HOME Or MAILING ADDRESS (if/Different from Site Address) <br /> C-S — l\ �/1 L A // Cx4treet Number Street Name <br /> CITY STATE ZIP <br /> GL`s <br /> PHONE#f ExT. APN# LAND USE APPLFFATION# <br /> PHONE#2 EXT. BOS DISTRICT / LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CF \ i 1 /�1^J� ���✓ d. PLV M f,� ' CHECK if BILLING ADDRESS/ <br /> BUSINESS NAME C C PHONE III <br /> ExT' <br /> HOME Or MAILING ADDRESS FAX# <br /> 1 . (A/14-' (2�S) S- `l 3 <br /> CITYC&3-- <br /> r R e STATE ZIP <br /> L (� l <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 /> 1 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,4111"da TATE and FED L laws. <br /> © <br /> J,APPLICANT'S SIGNATURE: `1 DATE: 12 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I 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 provided(�me or <br /> my representative. /W7 <br /> TYPE OF SERVICE REQUESTED: C ( D1/L G V-� FNr <br /> COMMENTS: f-C) <br /> �J�` 78 <br /> 1• ! r t � MSR �iH <br /> Ty <br /> CO <br /> ACCEPTED BY: EMPLOYEE#: U✓� DATE: 2 ,� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6 , PIE: T Q� <br /> Fee Amount: 15-2— Amount Pal 4sa.bD Payment Date <br /> Payment Type v i Invoice# Ch!6k# Receive By:/] <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />