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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVI� E LI i T# <br /> Com �rlc/ `J go, CU/ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> R <br /> FACILITY NAME <br /> /O <br /> SITE ADDRESS 79 ,O 5 /1/R POK/T � A I/ ST-d GKTQ/1� 9 5-,' <br /> Street N/umber Direction /-{ StreeettVNamer Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Z)u84./A/ lfjL VP <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> D / fflag <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> LZ 7 - s - d <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ! EXT. <br /> E <br /> HOME or MAILING ADDRESS FAX# <br /> CITY —rU n� yt $TATE 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 /> 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, ST E and FE AL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /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 a5 It Is available and at the Same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED:56/L SC((fA08t /W/T2 PAY iEN <br /> COMMENTS: 4 <br /> 20 <br /> SAN JOAQUIN COU TY <br /> 51WIRONIVIENTAL <br /> HL L1ii <br /> DEPART M NT, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 Q �j <br /> Fee Amount: Amount Paid 0 — Payment Date <br /> Payment Type Invoice# Check# S' J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />