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SAN JOAQU... COUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t � 0 ';�3 0 6?- 1 ]L-�— ' 1 � <br /> OWNER/OPERATOR ' <br /> I r "'5 /J CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> i <br /> SIT ADDRESS / 1 ° 7 <br /> Street Number Direction � t Stre t Name fi Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) I (4 ( `,� r I ` t <br /> Street Number J Y I /�}- street Name J <br /> CITY ( C)( 1/,-y�T/t- STAT! I ZIP (� 1 <br /> 5'7 10 <br /> P^ONE#a_ �! � — ���E,�T• APN# LAND USE APPLICATION# <br /> PHONE#2 ,o/ EXX/T. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR v' ` I r ( 1 n I (� C CI <br /> J J L-(� V 1, CHECK If BILLING ADDRESS <br /> BUSINESS NAME G� \ 21�O P Co o[� 4 6 <br /> 2 C -T <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY C �( ) r STATE I tl} ZIP �/� D <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 /> 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: ( )���1 �I 1'�(J (C I a 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 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. n ,� , / <br /> TYPE OF SERVICE REQUESTED: V) (AnQ,� V V w,1 �/ S I V r <br /> COMMENTS: / l A t6 LOU. 10 <br /> I 7 At z/ i� I <br /> o U(� �3 ��A ° 201> <br /> S FN� QUly <br /> Hfq�Ty�P,r�y,FNTUIy�, <br /> ACCEPTED BY: tyl LAI I 1.11r," EMPLOYEE#: DATE: <br /> ASSIGNED TO: ^1 SG EMPLOYEE#: DATE: ' I <br /> Date Service Completed (if already completed): SERVICE CODE: P PIE: LOO <br /> Fee Amount: G Amount Pal•_ l C� (� Payment Date <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />