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SAN JOr.cauN.l COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Or Property FACILITY ID# SERVICE REQUEST# <br /> Jwd jha,�k" ::: I �� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADORES ('.L./��%��. <br /> O� Street Number r¢¢tlon Dir tNam¢ w �U Q �M �LodeClO <br /> HOME Or MAILING ADDRESS jlf Different from Sit Address) <br /> oC. �, t Street Number Sheet Name <br /> CITY S c4fmr Z <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# b <br /> PHONE#2EXT• BOS DISTRICT LOCATION CODE <br /> (,2M t P 1 o-S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> K If BILLING ADDRESS <br /> BUSINE S NAMF,- <br /> PHONE . ' - 77L NI t ExT. <br /> H EOFAx A <br /> • Z If ) <br /> CITU Sm ZIP /a /_' -7 /t <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 /> 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 9 EDE aGG? <br /> APPLICANT'S SIGNATURE: DATE: N/I(o%7 <br /> PROPERTY/BUSINESS OWNER IC4 OPERATOfR.I' ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IIS not the BILLING?' Tv proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO TION: 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 assessmow. ,mation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr,@„V Th/TC. 0.gr <br /> my representative. IT <br /> TYPE OF SERVICE REQUESTED: () Gn OkwC O <br /> COMMENTS: SqN✓ 2Q// <br /> V1opp��0��/Y <br /> ACCEPTED BY: a //✓5 O EMPLOYEE M DATE: <br /> ASSIGNED TO: /1 n U EMPLOYEE#: r- DATE: <br /> Date Service Compl ed (if already completed): SERVICE CODE: SC�J23 PIE' <br /> Fee Amount: Amount Pai11:6T/-7rDn Payment Date lgl7 <br /> . ,n <br /> Payment Type Invoice# Check# Receiv6dBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />