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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 7 riftUU 2�LlNq LP SRUO 051 S <br /> OWNER / OPERATOR <br /> � / C' CHECK If BILLING ADDRESS O <br /> FACILITY NAME n � <br /> d <br /> SITE ADDRESS / % L L� 0 <br /> lldlo4ler LGtNCt' �70 70 <br /> Street Number Direction Stree[ Name City Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( �z,> '12 -7 -7653 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> U C' YY J�V1 YV1e lox 14CHECKIfBILLING ADDRESSW <br /> BUSINESS NAME PHONE # ExT. <br /> HOME or MAILING ADDRESS FAX # <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 /> 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 : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ ERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT A S2 <br /> If APPLICANT IS not BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS 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 provl t�e or <br /> my representative . <br /> K PA <br /> TYPE OF SERVICE REQUESTED : �v� . <br /> COMMENTS : r , <br /> [ <br /> SIV <br /> COU UN <br /> FP,yRr�ENT <br /> ACCEPTED BY: EMPLOYEE # : DATE: 23 to) <br /> ASSIGNED TO : Qt 1 1 EMPLOYEE #: DATE : 1 23 IGf <br /> Date Service Completed ( if already completed ) : SERVICE CODE : ( G PIE : 130�6 <br /> Fee Amount: (1I (� Amount Paid D 6Payment Date 2 <br /> Payment Type Invoice # Check # Received By : <br /> 72 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17/08 <br />