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SAN JOAQUI vl'C:OUNTY ENVIRONMENTAL HEALTH DVARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU ST# <br /> ccs 15�utio� C�(ji V-5-7 ( CyJ- 0�� <br /> OWNER/OPERATOR <br /> Eae ` 4(( I o "5rrtl(?n fic CHECK If BILLING ADDRESS <br /> ' FACILITY NAME <br /> SITE ADDRESS <br /> 330� W / I(AYvin�et'' lul?P <br /> 1 <br /> 1 Street Number Direction Street Name Ci Zi Code <br /> HOME or CLING ADDRESS III Different fropt Site Address) <br /> O -J �Gp �� Street Number Street Name <br /> l;lE Z <br /> 5uyi mar l//'T`n- �yo. <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> V60) 759 -462 0 '7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> yea <br /> SI' � � CHECK If BILLING ADDRESSBUSINESS NAME 1 / III L PHONE# EXT. <br /> �CCff c� /�G{1-� . u SP�v/lP ��c. 6` 7517 Z'Ig <br /> HOME or Ma�� A�DRESS FAX# <br /> %% VA 3e//- <br /> CITY J5an I' a f vo STATE 00 2 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER I OTHER AUTHORIZED AGENT ❑ U/l(° �j PS�G1fy1� <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 assessor t information <br /> t0 the SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time It IS pr /OCI]le Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: V) <br /> COMMENTS: <br /> Q O 01�Y)-e� I/ gRO018N/?ONCti47jyDNT <br /> 7-y <br /> MRNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ V / <br /> ASSIGNED TO: EMPLOYEE#: DATE: "-1 O_ � X <br /> Date Service Completed (if already complete4. SERVICE CODE: I PIE: <br /> Fee Amount: Amount Paid 0 Payment Date 7� Z <br /> Payment Type Invoice# Check# /� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />