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;h 0v S7 2. <br /> SAN JOAQUISOUNT ENVIRONMINTAL HEALTAPARTMEN -_._._.__.._.__.. <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 71ERV4GE,R <br /> C-7 v o <br /> --C4�; <br /> OWNER/OPERATO�j �I <br /> /" /{ �n „I , CHECK If BILLING ADDRESS <br /> FACILITY NAME (,� (� j� <br /> SITE ADDRESS , />. / Q <br /> Street Number Direction Street Name Cit 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 /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> � � ^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# _ ExT' <br /> HOME or MAILING ADDRESS FAX# _a <br /> CITY I STATE ZIP 'A (� <br /> BILLIN ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowl dge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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,Standard , TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: (//> <br /> PROPERTY/BUSINESS OWNER❑ OPE OR MAN ER ❑ OTHER AUTHORIZED AGEN�� <br /> I APPLICANT is not the BIL G PAR roo o authorization to sign is requir,Cd itte <br /> l p fl g <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ECEIVED <br /> COMMENTS: N0V 2 1 2008 <br /> #� <br /> SAN JOAQUIN COUNT`t <br /> u EN-TEPR TAL TENT RUS <br /> .. 1-1EA�TH Q <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 1;1) Amount Paid ip L[-7 Z Payment Date t <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />