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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # <br /> ER P;Q EST # <br /> S ,-rte <br /> S � L/ <br /> OWNER / OPERATOR ` CHECK if BILLING ADDRESS <br /> FACILITY NAME VL (1 t '� c 0 <br /> 2 <br /> SITE ADDRESS r Y, 1"c�l �' � �; CZ •- � I �' () i<'1 c� � �� <br /> ( C? Z Z Street Name Ci ode <br /> Zi C <br /> Street Number Direction <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ; C + Y 1 en t j� V C <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY S S C'LL� l c. V1 L ( S LL � / `3 t_} O ,5 <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> L % <br /> PHNE ;tZ Exr. BOS DISTRICT LOCATION CODE) <br /> CONTRACTOR / SERVIC'E/ REQUESTOR <br /> REQUESTOR -� ' /, L� C I1 � I V1 Ilk @ V y CHECK if BILLING ADDRESS <br /> ExT. <br /> BUSINESS NAME PHONE # _ <br /> fFAX # <br /> HOME or MAILING ADDRESS L, / J v (r) c �fL f � 'J <br /> STATE C ��I ZIP <br /> CITY S e> 6U- I' Y cvw C C %S L L) <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, =ATOR / MANAGER <br /> WS . <br /> APPLICANT' S SIGNATURE : �` DATE :PROPERTY / BUSINESS OWNER ❑ ❑ OTHER'•AUTHORIZED AGENT <br /> Nl et4 . - <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tille <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 assessme forma n <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time It IS r I or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : 1/) 5 7' fir, . `, d • , � <br /> COMMENTS : 7 S ✓OqQ ?0,, <br /> I Ty ,I/V V�H� <br /> NT <br /> ACCEPTED BY : EMPLOYEE #: EDATE : 'EEEASSIGNED TO : _ EMPLOYEE #: '7 <br /> N � ✓ <br /> $ERVICE PIE : <br /> Date Service Completed (if already completed) : CODE: C C� <br /> Fee Amount: Amount Paid Payment Date <br /> rPaymentType <br /> Invoice # Check # Received By : i <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />