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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property v4Wj, A FACILITY ID # ERVICE REQUEST # <br /> oe 1) i Aga 71�920J j ) 1)q�? c�:5 <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 5 � 7 l /I Z � , / � � <br /> Street Nu/tuber :Direction G� /7` Street Name I/ Ci / Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIPT <br /> PHONE #1 E'R• APN # LAND USE APPLICATION # <br /> AU <br /> PHONE #2 ExT. BOS DISTRICT L.iJCATIN�CODE <br /> � 7i ` 5 a���1ryJ QUIN COU 7y <br /> CONTRACTOR / SERVICE REQUESTOR H�LTH DEPARTMENT <br /> vir <br /> ft [VTNMT <br /> REQUESTOR r7 '�,'/�— CHECK if BILLING ADDRESS ❑ <br /> ! <br /> �� 1 / <br /> BUSINESS NAME w` r PHONE # Exr. <br /> OCL 3 2,5 - 1 <br /> HOME Or MAILING ADDRESS FAX # <br /> I'o & A i ( 113 <br /> ) L �/ <br /> CITY / /rJ ` STATE 0! a (/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 applic ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SeTA R L laws . <br /> APPLICANT 'S SIGNATURE : r DATE : <br /> PROPERTY I BUSINESS OWNER OPERATOR I M GE ❑ OTHER AUTHORIZED AGENT ❑ / (J t/ <br /> If APPLICANT is not the BILLING PART, pro of authorization to sign is required T tle <br /> AUTHORIZATION TO RELEASE INFORMATIONo n applicable , 1 , 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 /> /� <br /> COMMENTS: <br /> 0 /' <br /> 5ere <br /> 51e /17; Y4P <br /> ` c7 <br /> ACCEPTED BY : EMPLOYEE #: G{, DATE: OLIL) <br /> ASSIGNED TO : O EMPLOYEE #: V DATE: _ <br /> Date Service Completed (if already completed) : SERVICE CODE: I P / E: J 3 (O <br /> Fee Amount : S Amount PalL�s� � D Payment Date � Z <br /> Payment Type Invoice # Check # C 42�Z �� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />