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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cris P-000�)GG 2-t'�24y <br /> OWNER/OPERATOR <br /> /-V7 <br /> I j ^/� CHECK If BILLING ADDRESS <br /> FACILITY NAME `l <br /> C ttyvi,,. 441 /`-0/T L tis <br /> SITE ADDRESS LYy s /-V <br /> t <br /> IAklriz(,.,.� <br /> Street Number Direction Street Name city Zhl Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1EXT. APN# LAND USE APPLICATION# <br /> (�i off) SIS- 0 000 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 application and that fhe work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE 7adTEDERA S. ) <br /> APPLICANT'S SIGNATURE: DATE: I31/ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7';rle <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C(✓�� (1-6u 1 I U� <br /> COMMENTS: <br /> S I O I � N JOAQUIN COU TY <br /> SA <br /> HEAL <br /> HEALTH DEPART NT <br /> ACCEPTED BY: �yr EMPLOYEE#: DATE: -2- <br /> ASSIGNED <br /> yASSIGNED TO: ` r EMPLOYEE#: DATE: 2 <br /> Date Service Completed (if already completed): 2/ 7,/1♦Gl SERVICE CODE: CU i P I E: I c(Q L <br /> Fee Amount: Amount Paid VS 2 _ Payment Date 3 <br /> Payment Type Invoice# Check# 3 L-�) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />