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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 1� L <br /> FACILITY NAME <br /> SITE ADDRESS <br /> SIM / <br /> Street Number Direction U Street Nam City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C6?5 (Ii�rwl r3(u;� <br /> ,o <br /> 55 Street Number Street Name <br /> CITY 1 STATE ZIP <br /> Cv� c <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (-7 1) 3�tt`�. 7©& -/ <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> 396 -H9g1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> „v CHECK If BILLING ADDRESS <br /> BUSINESS NAME �,—�,.�� ,�--n� '1 <br /> PHONE# EXT. <br /> ►� L - y74 I <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S c7S C 1A STATE Z c.)� ZIP <br /> �.� <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 <br /> or activity will be billed to me or my business as identi ed on this form. <br /> I also certify that I have prepared this application i th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT n -F S. <br /> APPLICANT'S SIGNATURE: DATE: s/ C$I zC�ZC� <br /> PROPERTY/BUSINESS OWNE4435- O O OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILL 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �� Y�tj I l R T <br /> COMMENTS: <br /> MAY 0 6 2010 <br /> SA NOAI QUIN COU <br /> HEALTH DEARTM N'r <br /> ACCEPTED BY: VVV1 I EMPLOYEE#: DATE: <br /> ASSIGNED TO: b, EMPLOYEE#: DATE: `r <br /> Date Service Completed (If already completed): SERVICE CODE: o ( PIE: <br /> Fee Amount: R vs <br /> Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />