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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tyre of Bus�ai`ess^orr�Pjrro�pe�rty, �j FACILITY ID# SERVICE REQUEST# <br /> N I f l/�lif� <br /> OWNER/OPERATOR �p �1/\ IS/1 , /11 n� <br /> U/VVI CHECK If BILLING ADDRESS <br /> FACILITY NAME :a 1 <br /> SIT DRESS ` (]"` �,(tx� ��/�y��/�� (� <br /> Street Number Direction `� ' w -`Tree' ame �, 1 \ Zi Cotle <br /> HOME or MAILING ADDRESS (If Different fSite <br /> rom dresk <br /> Street Number Street Name <br /> CITY C ZIP <br /> PHONE EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION COOE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR p <br /> ' , <br /> /7 Y I/ CHECK If BILLING ADDRESS� <br /> BUSINESS NAME < I �/JI HONE k <br /> EXT. <br /> HOME or MAILING ADDRESS to C (� (� FAX# <br /> CITY 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 /> I also certify that I have prepared this ap i ifa the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE oe L la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/l ❑ 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, 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'nformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is prOVl "IOr <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 17 Wd <br /> COMMENTS: <br /> BryViRpUINC <br /> ��D PAR�EN <br /> ACCEPTED BY: �� �/� ��� EMPLOYEE#: (,���� DATE: <br /> ASSIGNED TO: rn •-� t ✓'I// EMPLOYEE#: DATE: C(_ <br /> Date Service Completed (if already completed): SERVICE CODE: ` PIE: Ileo <br /> Fee Amount: `(�•Z Amount Pai A�.L)U I <br /> Payment Date C /L /9- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />