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SAN JOAQUIN G. ILINTY ENVIRONMENTAL HEALTH DEPAi,iMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R-9 01 5v lPe/ ep�� <br /> OWNER/OPERATOR L� D /]��/�G� CHECK If BILLING ADDRESSEE <br /> FACILI NAME <br /> SITE ADDRESS Y d ��/ �IV r <br /> G / �1`�0�^ �� cty 7 <br /> eef Number Direction <br /> HOMF O/r�MAIILIINNG�A/Jorim- - (If D'fferent from Site Address) <br /> Zt/21 // Street Number r e Name <br /> CITY ( STATEf& ZIP <br /> 12; Z6 <br /> PHONE#1 Exr. ApNg LANG USE APPLICATION# <br /> c2oq) Z p S3 <br /> PHONE#2 rr EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORv nV O �ij CHECK If BILLING ADDRESS® <br /> -e �/ PHONE# ExT. <br /> BUSINESS NAME -� .r� <br /> HOME or MAILING ADDRESS ( FAX# <br /> tZoZ r✓ ✓ ( I <br /> CITYSTAT ZI <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 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: v DATE: /7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof Of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property loc^.ted 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. IJ4 <br /> TYPE OF SERVICE REQUESTED: FoViNcicV n Ice, <br /> COMMENTS: <br /> SAN 1 � 2016 <br /> Ejy AQUI <br /> NEA[TH pE ER O�Nry <br /> tip <br /> ACCEPTED BY: t/l/1 O�/I Vl l 1 f� EMPLOYEE#: DATE: <br /> AsSIGNEDTO: �ii EMPLOYEE#: DATE: vOU <br /> h-7 /1Q <br /> Date Service Completed (if already completed): SERVICECooe SCQuI PIE: I�d <br /> Fee Amount: () Amount Paid /3O Payment Date <br /> Payment Type &4A— Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />