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SAN JOAQI,r.v COUNTY ENVIRONMENTAL HEALTH L APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER!OPERATOR O r/ ) ^ � �` <br /> — — 2 e f CJ l V — — CHECK If BILLING ADDRESS Lam! <br /> FACILITY WME <br /> Ss�cyU <br /> ��_ S[reetf,umber Direction _StraC/ <br /> et Name _ Ci Zip Code . <br /> t <br /> HyuMEl�.[MADDRE�$ (If Differeytt fro Si e d�ess� <br /> /j�P� 1VV !/ r Street Number I _ Street Name <br /> CI STATE ZIP C 5 G)� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Qty ) [ 7— <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR. / SFRVICE R ,()UFSTOR- <br /> REQUESTOi• G �v — <br /> U CHECK if BILLING ADDRESS <br /> BUSINESS NAMc 0 S F / PHONE# .7 �EXT. <br /> HOME or MAILING ADDRESS- c— FAX# c <br /> CITY STATE ZIP <br /> BILLINGS 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 ication a e wor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TA an EDER ws. <br /> L <br /> APPLIC ANT'S SIt'NATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OP O /MA R ❑ OTHER AUTHORIZLD AGENT ❑ <br /> /f APPLICANT Is not the BILLING ARTY,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 at:)ve <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: F db S LL-� +LLT IC Y I pA D <br /> COMMENTS: <br /> N e.c ) O to n,'ef SUN 15 <br /> QV1N C0Ur1SY <br /> N jOA ENTA�- <br /> HEp�,�N DE Ap�M� <br /> 't.,CEPTEr EMPLOYEE#: DATE: <br /> ASSIGNED TO: -1 +Z EMPLOYEE#: DATE: <br /> Date Serri;:e Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />