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F <br /> SAN JOAQUIi OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S� �g ► IB°I <br /> OWNER IOPERATOR <br /> eaS CHECK If BILLING ADDRESS E] <br /> FACILITY NAME IA <br /> Co t n <br /> SITEADDRESS f ' '' 7A <br /> Cq I rV Sh et Number Direction CU l Itreet Name G� C Ee� <br /> HOME or MAILING <br /> II A� DDRESS III Different from Site Address) <br /> 7760 v\AVI e C�v Street Number Street Name <br /> CITYSTATE <br /> fih�O _ <br /> PHONE#1 (+f[/ En. APN# LAND USE APPLICATION# G� J <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK If BILLING ADDRESS❑ <br /> mad Un as <br /> BUSINE SNAME PHONE# EXT. <br /> l le Coo IC-1 V1 w 9s� -8z�o <br /> HOME Or MAILING ADDRESS FAx# <br /> O C— Aa vted C I ) <br /> CITY STATE Ce ZIP(j,!;,3 30 <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 identified on this form. <br /> I also certify that I have prepared this a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar S ATE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/s to assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tth ti_me it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �y <br /> COMMENTS: <br /> 4 <br /> /y, N,,O U�yc �DI9 <br /> hpRp RFT q�Nry <br /> MF'I'T <br /> ACCEPTED BY: J- ,,n (1 EMPLOYEE M DATE: R L1 <br /> ASSIGNED TO: '°l V EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (� I PIE: <br /> Fee Amount: +Cil Amount Paicp/5� bD Payment Date %2, 11 <br /> Payment Type`–f Invoice# Check# 6� Z� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />