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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR , , 1� /I} CHECK if BILLING ADGO <br /> FACILITY NAME W <br /> SITE ADDRESSr�.�j `i � to VU� a6�L&A � 5ao � <br /> �G 6 (� i <br /> Street Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S® D V <br /> Street Number St et Name <br /> CITY GG STATE Zip a3 <br /> T� �bv1 l"' t�' <br /> PHONE # ) , Exr. AP <br /> # LAND USE APPLICATION # <br /> PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � r ` CHECK If BILLING ADDRESS <br /> E # � <br /> BUSINESS NAME PHON <br /> SUV y� � ,jS � U'� & I 1 sWIJEx-r. <br /> S' <br /> � r y `'G <br /> ll ( <br /> Or MAILING ADDRESS FAX # <br /> 6 <br /> CITY STATE Cik ZIP q 00 t J� <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 /> 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 laws . <br /> APPLICANT ' S SIGNATURE : � � .{ tp l �zd V' CLQ - DATE j�, � a-/(���� <br /> PROPERTY I BUSINESS OWNER ElOPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I/UOLL40l✓ O'°� Y <br /> If APPLICANT Is not the BILLING 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided t0 me Or <br /> my representative . 74 <br /> TYPE OF SERVICE REQUESTED : / r? 0 <br /> COMMENTS : <br /> ACCEPTED BY : s D I�i7 i EMPLOYEE # : DATE : 151, <br /> ASSIGNED TO : l �f �� a EMPLOYEE M DATE : 4�5 <br /> Date Service Completed ( if already Completed) : SERVICE CODE : /9e ,2q.0 <br /> Fee Amount : �*Vff 2 Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />