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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST It <br /> '5C CO$OS3 I <br /> OWNER/OPERATOR n rI I <br /> N an CHECK If BILLING ADDRESS <br /> FACILITY NAME 9 vaf <br /> � J <br /> SITE ADDRESS o,j 2 B I� 5C4Q <br /> '/f Streel Number Direction street Name <br /> c1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ` G/ 0 <br /> J StreetNumber Street Name <br /> CITY �� % STAT y ZIP <br /> PHONE#1 EU APN# LAND USE APPLICATION# <br /> ( ) 20 G �z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // <br /> Ya Qp L O I r q C - CHECK If BILLING ADDRESS <br /> � <br /> BUSINESS NAME A l LL.. ^ /S PHONE lI 0 <br /> lA Vr <br /> HOME Or MAILING ADDRESS 0 VLC FAX <br /> L A� �L ( ) <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 /> 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 f S. <br /> APPLICANT'S SIGNATURE: �j DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR f MANAGER ❑ \ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titre <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It Is available and at the same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S I <br /> COMMENTS: cc ^^ <br /> APR ?g <br /> HJQ4 U/N Cp <br /> ACCEPTED BY: EMPLOYEE#: DATE: fpgRTiyfvrAt <br /> ASSIGNED TO: J Vl2agV;�� <br /> EMPLOYEE#: DATE: <br /> Date ServiceCo-q Impleted (if already completed): SERVICE CODE: 0� PIE: <br /> Fee Amount: Amount Paid/77/ �D Payment Date / <br /> Payment Type Invoice# Check# c70S 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />