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SAN JOAQ* COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> %c t - SS ) ()1111 <br /> OWNER/OPERATOR <br /> � Q^ CHECK If BILLING ADDRESS 13 <br /> FACILITY NAM C <br /> leu �r a. <br /> SITE ADDRESS W <br /> Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) '#Y'Y /�, <br /> Street Number W'I'SStreet�me <br /> CITY STATE ZIP <br /> G X1521 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> Lp-►u LP <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 ` p E# ExT. <br /> L_J.� Y ldZ l o�u <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE(y 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, Standard ,STATE and FEDERAL laws. i <br /> APPLICANT'S SIGNATURE: DATE: 'f •�-�D •(- <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLIN 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 assessmei frmation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr id L7— litr <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: a CdJ`kA�o V\ 111AI <br /> COMMENTS: <br /> Afaoy����o� <br /> rynPpgR 14 <br /> r. <br /> ACCEPTED BY: M G\ J EMPLOYEE#: O DATE: 6 <br /> ASSIGNED TO: l ,e EMPLOYEE#: ^�Gi 7 DATE: 6/7,t/7, / <br /> Date Service Completed (if already completed): SERVICE CODE: 0 6 ` I P I E: 4 U3 <br /> Fee Amount: �� Amount Paid '> 3G3, Payment Date l� I <br /> Payment Type Invoice# Check# l Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />