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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N 8 <br /> O /OPERA ORS <br /> CHECK If BILLING ADDRESS El <br /> FACILITY <br /> %SITE ADDRESS ( I/r,^�0 `��Iy G�� 2D2 <br /> Street Number Direction ' `'' ST�me - v _` Cll..• 1'2D2 <br /> - <br /> SITE <br /> Qr T LIN 7 RESS,(If Different from Ite Address) <br /> t v'Ili Street Number Street Name <br /> CI <br /> MT <br /> ZIP -' <br /> PHONE f Exr. APN# AND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ESTO (JR <br /> !\y� CHECK If BILLING ADDRESS <br /> t�/ <br /> INES� AE, PH (ftqk EZ , <br /> N � NE <br /> v <br /> HOM o�MAILIl ADDR S �� I^ FAx# <br /> L I <br /> CITY STATE ZIP C `� <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 <br /> or activity will be billed to me or my business as identified on this fornl. <br /> I also certify that I have prepared this a liTanF at thew k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STAL laws. <br /> APPLICANT'S SIGNAT/U�R.,E: DATE: �� Q <br /> ROPERTY/BUSINESS OWNERILI_-- OPE TOR/M THER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BlLLtNGPARTY proof of authorization to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmli;pttal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anQ aC[ )p��ly�e it is <br /> provided to me or my representative. RE ,'r1/ <br /> TYPE OF SERVICE REQUESTED: -" <br /> EDUESTED: AZU <br /> (I5�, � n &'rw �t <br /> COMMENTS: tt <br /> SAN JOAQUgT1IN O <br /> NELH) MEN <br /> TAL <br /> " v `��'�-- O.f ll�I��r,vll� ��S'�vTID✓� ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: g DATE: 11 q <br /> 2d <br /> ASSIGNEDTO: I EMPLOYEE#: 3 d' DATE: ' 9 20 <br /> vUyFeDate Service Completed (if already completed): SERVICE CODE: G�' P E: 1(10.2- <br /> Fee <br /> e Amount: G Amount Paid5a Payment Date 11 20 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />