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SAN JOA(juIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> �9 S206 7331 <br /> OWNER/OPERATOR <br /> /C eS CHECK If BILLING ADDRESS <br /> FACILITY NAME a eo 4 /lz <br /> SITE ADDRESS ZZ / <br /> Sireel Number Direction Street Name C ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) `-1 ��? P <br /> O� S[reet N1umber ^ / "' Street Name <br /> CITY -=S ! /�I WSJ T ZIP <br /> PHONE#1 C EXT' APN# (LAND USE APPLICATION# <br /> PHONE#2 /; EXT. BOS DISTRICT LOCATION CODE <br /> Vy CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR i t <br /> C >� CHECK If BILLING ADDRESS <br /> BUSINESS NAME r� ^ ^� /` - � �C � P ONE <br /> HOME or MAILING ADDRESS FAX# (O <br /> ( ) <br /> CITY WE 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 thl I have prepared this application and that the work to be performed will be done in accordance with ail SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE.qnA FEDERAL la <br /> APPLICANT'S SIGNATURE: ` ` DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR/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, 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 /> to 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: J G 1e, LIf O R NT <br /> COMMENTS: O <br /> c'nalt [q-e- Grr Oumg- SANJOAT O6 ? 15 <br /> £fy�'gQUlry <br /> hfALTy of o 7-A �Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: / /\ <br /> ASSIGNED TO: �C;^�. EMPLOYEE#: DATE: `6) <br /> to <br /> Date Service Completed (if already completed): SERVICE CODE: O E: <br /> Fee <br /> Fee Amount: ca Amount Pai/ 130.6)D Payment Date <br /> Payment Type e,"e. Invoice# Check# Received By:av <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />