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SAN JOAQUI•COUNTY ENVIRONMENTAL HEALTH D PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST## <br /> y-eb7gdd /9 <br /> OWNER/OPERATOR <br /> W I W /�,/�,l CHECKifBILLINGADDRESS® <br /> FACILITY NAME t l 1 t Y <br /> � <br /> SITE ADDRESS cs <br /> -3 <br /> �� <br /> et Number Direction Street Name XF/- Gifu Zi_ <br /> HOME Or MAILING)ADDRESS ((if Diffe/rlent,from Si1te�Address) l <br /> Street Number Street Name <br /> CITY rSTATE ^ r, QIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (IZ5)G1-6 Co 5"7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU'eSTOR y � <br /> CHECK if BILLING ADDRESS CSE <br /> BUSINESS NAME PHONE# wig EXT. <br /> W ► 1 R'L5 � (O 5 7 <br /> HOME or MAILING ADDRESSFAX# <br /> go a w <br /> CITY STATE CLQ ZIP qG)—� <br /> BILLING ACKNOWLEfDG MENT: 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, Standards, TATE and FEDERAIaws. L, <br /> APPLICANT'S SIGNATURE: - 7� DATE: ✓ <br /> PROPERTY/BUSINESS OWN OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLI ANT 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 prof to me or <br /> my representative. (Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 9 <br /> f{Nv y V <br /> hFq<T 90��ti ��16 <br /> h SFA <br /> qqT,�< �y <br /> ACCEPTED BY: EMPLOYEE#: DATE <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date SeRrice Completed (if already completed): SERVICE CODE: <br /> Fee AmountrJ-'� Amount Paid Payment`Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />