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SAN JOAQUw, COUNTY ENVIRONMENTAL HEALTH b.PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Z m 5> .�/1 Y Hn S'✓� ,n L,, <br /> SITE ADDRESS �� T I• � s��C"I `' C� (.,,� �✓�. <br /> �'PPr� oll) r v. <br /> ,7 S ZtStreet Number Direction Street Name <br /> HON Or MAILI G ADDRES�411f iffe nt from Site Address) <br /> L / Street Number Street Name <br /> CITY $TAT ZIP <br /> 51 S 12 <br /> �- <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (2c <br /> 22 61 <br /> --7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ GOR CHECK if BILLING ADDRESS <br /> BuTiss AME _ PHONE# EXT. <br /> HOME or MAILING ADDRESS `/-'!>V7- C �J'�t g FAX# <br /> i _ ( ) <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 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: t j��' L DATE: -Z2 / Z . <br /> PROPERTY/BUSINESS OWNEO!(" 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 prove,file Or <br /> my representative. rM <br /> TYPE OF SERVICE REQUESTED: r—ocd V e-Y 1 I C 1 t c'7h 04 <br /> COMMENTS: ylqr� L S.qN O 1 20� <br /> AQj <br /> HE LTH FR A� TY <br /> Me r <br /> ACCEPTED BY: C,n�/J� EMPLOYEE#: DATE: <br /> ASSIGNED TO: L n EMPLOYEE#: DATE:':t) <br /> Date Service Completed (if already completed): SERVICE CODE: P1 <br /> Fee Amount: 1 — Amount Paid Payment Date �x <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />