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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL`i? I-I DEPARTMENT <br /> SERVICE REQUEST <br /> '1 Ifof Business or Property FACILITY ID # SERVICE REQUEST # <br /> "e `ti"V ;ti w;i2 I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> r:Aciurf NAME <br /> SITE ADDRESS I' © � `� av) se S~t llalti 'e Ca . 95 r3w) <br /> Street Number DI ton Street Name CI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number S re o A �g� „ � <br /> CITY STATE zip C /V <br /> (HONE ;I EXT• APN # LAND USE APPLICATION ft t °/A t/ <br /> / _ 2019 <br /> PHONEfYI Ext. BCISDISTRICT LOCATION qU/I1 <br /> ( 1 HSAIT O� t <br /> CONTRACTOR / SERVICE REQUESTOR NT <br /> R;-.AAQ IGSTOR <br /> CHECK H BILLING ADDRESS <br /> BusmEBu NAME ,� I - PHONE # EXT• <br /> lGw1t9✓t l � 7�' � �� vM �PYv � cC } �Ic . 42r `/ <br /> I omrr Or MAIL= ADDRESS � FAX <br /> GI iYi`'1' h / / 62G S7ATE C� ZIP � L�� <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 writh all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE : _[d�ll F'G* (J .0 /L- DATE : �j <br /> — - - <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER OTHER AUTHORIZED AGENT 0 <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 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 : !/t Y/ d/o,9 b1le r e� 1J i4 (lcIt' aadl (meta( <br /> COMMENTS: �O / 1 Q ✓ r` / /) / U� {j LfrG� �2/�e /sJf /�Li �il� ' / 60 ( � yr/(�l✓� A ,t4 J <br /> d <br /> ; 0 t v / PIs 1 Ilea t~ l7V � � �t drn� �'t/� e �O P dc/ - Wo c <br /> ACCEPTED BY: EMPLOYEE #: C DATE: <br /> ASSIGNED TO: !✓ r/fuw• ,/ EMPLOYEE M DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: ' NEW <br /> Fee Amount. ! Amount Pal OD Payment Date <br /> Payment Type �� Invoice # Check # gbF77�[3S3 Received By: <br /> EHa 48-02-025 <br /> 07/17/08 SR FORM (Golden Rod) <br />