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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> / SERVICE REQUEST <br /> j ;Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 512iNb -7a5-79 <br /> ER I OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> F! i-.-Q IC �G CO -4 '© � 2� <br /> 3 � <br /> SITE ADDR S Q <br /> (" Street Number Direction eet Na v l--'C ZI Code <br /> 1-15 , <br /> HOME or�MAILING ADDRESS (If Diff rent from Site Address) <br /> Street Number Street Name <br /> CI ^STATE ZIP f go <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (a OT ~ c7f--.>Ci <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> QUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS N EY� PHONE# C,) -a 7 Exr. <br /> HOME 0AAAILING ADDRE SFAX# <br /> v o O <br /> CITY J ` STATE 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 /> 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,Standar E and FEDERAL Iajvs. / <br /> APPLICANT'S SIGNATURE: 7 'l�C G�� DATE: / <br /> PROPERTY/BUSINESS OWNER. OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT ❑7 <br /> If APPLICANT IS riot 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 as It Is available and at the Same time It IS provided to me or <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: ��^!► <br /> COMMENTS: <br /> .?-, Ndo, <br /> 3 018 <br /> H�Th FpgRN q N,Y <br /> M T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /\ P I E: D <br /> Fee Amount: Amount Paid Payment Date 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />