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SAN JOAQUw. COUNTY ENVIRONMENTAL HEALTH 6.0ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> --�--6 <br /> OWNER/OPERAT0 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME—Tvv— <br /> SITE ADDRESS <br /> �-3� (I�IOYn t r c iGrv► �►�Z�-- <br /> tr t u ber Direction � StTeet'Name � CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address)It <br /> tree[Number Street Name <br /> rlC/V IVA(A VA <br /> CITY �vLLG�f U� STATE ZIP <br /> 1 i <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20q Zi CIO 016 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ^ /�2- r <br /> wCHECK If BILLING ADDRESS <br /> BUSINESS NAME /J J 11 PH E# EXT. <br /> tnc 2 t_t C �1 C1 Y-1303— <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 's— STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, ther \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 an FEDERA S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER q OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tille <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: w1k i Cte I t) inch <br /> S <br /> COMMENTS: 'V <br /> J <br /> l� /k GJI c� OVJ(lSgN�O �8 2pj <br /> y FNViR <br /> �t TN pEpgRNTq H <br /> ' I T <br /> ACCEPTED BY: La <br /> T. <br /> v� EMPLOYEE � DATE: <br /> /, , I <br /> ASSIGNED TO: EMPLOYEE M DATE: /9 <br /> Date Service Completed (if already completed): SERVICE CODE: O� I P I k/03 <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 />