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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR-JCHECK If BILLING ADDRESS ❑esse C� � da � <br /> FACILITY NAME /� ai i " vi s C° � 4 rco Aeh <br /> SITE ADDRESS / /00 I �9 SotMENEWIN �— <br /> Street Number Pirection 81reet Name C I Co e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number SireetNome <br /> CITY STATE ZIP <br /> PHONE 99 ExT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR eS ell Q z <br /> CHECK If BILLING ADDREMENEWINh <br /> NEW <br /> S. <br /> va da lv <br /> BUSINESS NAME PHONE # Exr. <br /> 61 &0*10%A d PPYo lev-�-. Serwrees rb, c . 9 : 'S' }0 - 080 <br /> HOME or MAILING ADDRESS ► ( � FAX # <br /> ( ) <br /> CITY C / STATE zip <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized <br /> [lagent <br /> 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: .�� G' DATE . ►�'- - � S <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 provi d to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 1 Urs/ <br /> COMMENTS: 'n / ✓1 3 7 -�l C ( vi a L j 7/ S O Qr ru /I 7VbCj LJ 4r , <br /> 124V v ry e��MFNT�N <br /> ACCEPTED BY: �vO sem„ EMPLOYEE #: /// DATE: / <br /> ASSIGNED TO : EMPLOYEE #: �/10 DATE: q 17 q <br /> Date Service Completed (if already complete : SERVICECODE. ' � P / E: / _/ <br /> Fee Amount: CP `'L' Amount Pai � �D Payment Date <br /> Ze <br /> Payment Type s w Invoice # Check # 76 3��> l Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />