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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 3 sS <br /> Type of Business or Property ' FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY E <br /> 47 <br /> , , / N �`(, <br /> SITE ADDRESS 2 gV f V " Y� 1 �VjC4 I 1t—Ar ` cf� j: ;;TD \ I 2ff7 <br /> Street Number Dlrection Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) A Y� <br /> Street Number Street Name � Y� C <br /> EFAI <br /> CITY STATE ZIP £. D <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # ` 2v <br /> ( �) 301 t SAN JO <br /> PHONE #2 EXT9 BOS DISTRICT MEAL tC"D ,AL <br /> le PA IV <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BypiriES8,BAME PHONE # C7 � � ExT. <br /> H-E70�IVIAILING /�DDREt� - `� tFAx ) <br /> CITY // / -{�� wt-p6NA STATE L_A ZIP q6 <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 la S . <br /> APPLICANTS SIGNATURE : - � DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATO-R ANAGER 11 OTHER AUTHORIZED AGENT 0 .r 0 �'il* <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 assessment information <br /> t0 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: VU l e, F— t Sff �t � <br /> COMMENTS: <br /> ACCEPTED BY: — EMPLOYEE #: DATE: "f �j _ 7 � 20 <br /> ASSIGNED TO : EMPLOYEE #: DATE: /5 ` t7 pi CW <br /> Date Service Completed (if already completed) : SERVICE CODE : ' q2 PIE : a3o q <br /> Fee Amount : 41 o i Amount Pa Payment Date 3 Z <br /> Payment TypeS A � Invoice # Check # D� Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />