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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of BusinessQbviroert FACILITY ID # SERVICE REQUEST # <br />bb-7-7at/ � <br />OWNERI OPERATOR n y \ <br />CHECK <br />I <br />�pR <br />If BILLING ADDRESS <br />FACILITY NAME V n 6r b U'a 11-1- S <br />�8�417 <br />SITE ADDRESS <br />1� <br />E <br />Street Number <br />Direction <br />Street Name <br />DATE: �I <br />"CI -`d <br />Zi Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />DATE: K— <br />D <br />Streat Number <br />SERVICE CODE: <br />Street Name <br />CITY <br />STATE ZIP 92-57 -3O <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />{ ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r <br />V" d C.t Gd 14 { /�- I 1 V el— CHECK if BILLING ADDRESS <br />BUSINESS NAME D�t b"' <br />_ _ Are PHONE # EXT• <br />y (j7.ts 11r <br />HOME or MAILING ADDRESS n d , -, FAX <br />CITY <br />STATE <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 />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQWN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �i �� �a (rho 1� DATE: <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT IS not the BILLING PARTY, proof Of authorization to sign 1S 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 />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED:(e� <br />'4 Y,N Aj— <br />COMMENTS: CI _ „'' Ir .. y <br />I <br />�pR <br />� <br />c � - <br />�qo�� <br />�8�417 <br />0 <br />1)7DNpe'v Ary}, <br />E <br />ACCEPTED BY:G Y144 41,6, <br />�� <br />EMPLOYEE #: <br />DATE: �I <br />ASSIGNED TO: �7 6 <br />EMPLOYEE #: <br />DATE: K— <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: � f7 , � <br />Amount Paid <br />C-./ 7.od <br />Payment Date <br />Payment Type <br />invoice # <br />Check # ' j �� <br />Received By: <br />EHO 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />