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Title <br />SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH LJEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />LC)/Ze.Y) - N S—q/ <br />OWNER / OPERATOR <br />9 i_-,-. iq €=- C Li .1-- 6- /Vt-- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ,_,0 <br />Rao <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />/6 /5 0 27v9E--1c71De--N/c- AO] Street Number <br />I <br />Street Name <br />CITY <br />/---41-MtDP <br />STATE ZIP <br />C4- <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX It <br />( ) <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 Of <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 EDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER CI OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 Au-nation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi4d45f)ty <br />0 <br />DATE: <br />my representative. <br />TYPE OF SERVICE REQUESTED: /c3 i ti Velit 'ok iw,-e-c-f e ,,,.., S p —111 <br />COMMENTS: ‘94Vd PC 2/) <br />,. kk, 9.1Q, . u4 <br />"tacre04,u,hycil <br />- oeimii--uivr, <br />ACCEPTED BY: iy?ore (I i‘ EMPLOYEE #: C) 00'1 DATE: at 4i,s? <br />ASSIGNED TO: it_...., •uvi 1,1 otr <5 EMPLOYEE #: 4_5-F1 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P/E: <br />Fee Amount: /5-a 4(1' Amount Paid Payment Date ) <br />Payment Type 7at-1:7) Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)