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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# / <br /> s L ODD 3D5-�- 4D- F, 0 7b <br /> OWNER/OPERATOIJ <br /> S . lu T / CHECK if BIL ING ADDR <br /> k calif <br /> FAciLHY NAME 3 , 0a+& -T" � d <br /> (� <br /> SITE ADDRESS rlV1 l <br /> Street Number I DirectionT StreetName city ZipCode <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE?1 EXT. APN# D r\ LAND USE APPLICATION# <br /> PHONE#Z ExT• K BOS DISTRICT LOCATION CODE <br /> ( ) C' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# 7x ExT. <br /> � �3'9 <br /> HOME or MINfpDRES5 i,S-&- <br /> FAx# ) <br /> CITY STATE /a 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 /> 1 also certify that I have prepared this ap nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar E and FE ERAt <br /> L7 <br /> APPLICANT'S SIGNATURE,_ DATE; <br /> ROPERTY I 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, 1, 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: <br /> �MENTS: " a-e>�+ :�.S S c .cz K- c L RECr-AYENT <br /> IT ;�CT73 Fo <br /> -tea �f�, o,�,t� S e,�©2 L ® ��Q 20�� <br /> CO <br /> ACCEPTED BY: or O-ee L' EMPLOYEE#: DATE: 1 C, -3-1 t <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already c mpleted): SERVICE CODE: !t P/E: 23 a <br /> =4 1 <br /> Fee Amount: Amount Pai c3 0.60 Payment Date d 34 <br /> �a <br /> Payment Type Invoice# Check# ( Z f 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />