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SAN JOACIUNY COUNTY ENVIRONMENTAL HEALTH Dtr'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property l f)# SERVICE Ob'U-ES�#� <br /> D tI/ 11 Ul <br /> OWNER It QIPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NA tor <br /> I <br /> 10TEAp�WDR ti <br /> r 5tC1 <br /> reef Number Direction Street Name � CI � Zi CoCIt <br /> HOr MAILING ADDR S (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PE#1 ExT• APN# LAND USE APPLICATION# <br /> HOM)) giro ajo ��� ►33�� <br /> PHONE#2 UT. BOS DISTRICT LOCATION CODE <br /> ( tog) PC. i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> Q, CHECK if BILLING ADDRESS <br /> vl <br /> BUSINESS NAM O ✓ T t0i 1 PH EXT. <br /> N <br /> Ho Epr MAILIN ADDRE S'r{N FA%# <br /> �✓� ( ) <br /> CI STAT ZIP ON <br /> BILLING ACKNOWLEDGEMENT: 1, 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 lic?tio d that the work to be performed will be done in accordance with all SAH JOAQUIN <br /> COUNTY Ordinance Codes, Standar , AT ERAL laws. <br /> CAPPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER('JQSI/ OPERA OR/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 provided to me or <br /> my representative. __`` <br /> TYPE OF SERVICE REQUESTED: �U ' .e— �a'F <br /> COMMENTS: ^ Cf 11A <br /> Y G. <br /> ^IU G <br /> 3gFM0QQU/ 8 ZGi$ <br /> hFgt;i-tt qQ nq� TY <br /> ACCEPTED BY: :-nA <br /> .�. EMPLOYEE#: DATE: <br /> - <br /> ASSIGNED TO: <br /> t�nEMPLOYEE DATE: <br /> Date Service Completed (if already completed): t/ SERVICE CODE: UIeI PIE: <br /> Fee Amount: ` Amount Paid /30 oo I <br /> Payment Date <br /> Payment Type Cf�t.�-dL- Invoice# Check It Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />