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SAN JOAQUOUNTY ENVIRONMENTAL HEALT PARTMENT <br /> op SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE,RE�2U�$Tt I <br /> �u p al�►5jc /t,(�G�c.LIN4 � �/SJot�S�r_ /�'�� �! -b �F� (� �'� <br /> OWNER/OPERATOR —7 <br /> / ( CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 1�-�t� L..pj D4--- 1 LL <br /> SITEADDRESS q-v$ <br /> �� TW�" <br /> Street Number Direction Street Name Ci <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Hl"IV3H 1V1N3lNN0 IAN3 <br /> Street Number Street Name <br /> CITY STATE ZIP «pZ j ti Nnr <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> C13AI30:113 <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT--71 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 5p-?J L(/ e.J,:7A <br /> CHECK If BILLING ADDRESS <br /> EE <br /> BUSINESS NAME tom/ACJ C PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> S t2 ✓L oA1 <br /> 4-vr-- c) Z a L <br /> CITY P y� T 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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �— / s DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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: <br /> COMMENTS: b' <br /> 17 <br /> ACCEPTED BY: EMPLOYEE#: DATE: Q l t l <br /> ASSIGNED TO: EMPLOYEE#: C DATE: (Q ( i <br /> Date Service Completed (if already Completed): SERVICE CODE: k C P I E: / <br /> Fee Amount: ] << z= Amount Paid l o Payment Date �e u I <br /> Payment Type ✓ Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />