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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FOA V Al"l e V 0 01`M � <br /> OWNER I OPERATOR POy eS <br /> Cv- ( CHECK If BILLING ADDRESS <br /> FACILITY NAME �•/nI / Un`/ �� <br /> SITE ADDRESS r/ Stre Street Numberredion J / m (]S2C6 e <br /> HOME <br /> _ <br /> Or MAILING ADDRESS (If Diff nt from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USEAPPUCATION <br /> (Z Moyotz <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> OC9 /,1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �j CHECK((BILLING ADDRESS <br /> BUSINESS NAME l.' 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,Standa <br /> APPLICANT'S SIGNATURE: Car wDATE: � -0 /,,/ <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirte <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 provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: f—'A •Pli", c�2d'C <br /> COMMENTS: A ^e v I •"�� B6_ T <br /> y�<ly1/1 <br /> eN% 'o*OjG' <br /> ARrA- <br /> ACCEPTEDBY: nNthfekIJ. EMPLOYEE#: DATE: <br /> AsSIGNEDTO: L"'L(A7e'7 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z�ZZ PIE: <br /> Fee Amount: $t_(rr-G (�'J Amount Paid C�s� v� PaymentJDate ,3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/77/08 <br />