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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OW <br /> I 0�3Cv0� 00 %,P S SS <br /> OWNER / OPERATOR <br /> ,/ `3p'o CHECK If BILLING ADDRESS � <br /> FACILITY NAME ` � C'�� ram ' J� '„ Y-'� 1�•�F�-� �� k� � ' l Gi <br /> SITE ADDRESS � W � � {�T� , -� L�C7 Ick .2, 4c:. <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> USIN+�E NA�YJEI �` / ��wAr �p' � , t �+� G PHONE III ExT. <br /> 323 �7 c 1 <br /> HOME or MAILING ADDRESS FAX # <br /> ( ) <br /> CITY Cq ( A'ra�A STATE < ZIP IozfL Cl <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, <br /> aS�TATT and FEDERAL laws , <br /> APPLICANT'S SIGNATURE : � Y" T � ` DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to <br /> my my representative. J <br /> TYPE OF SERVICE REQUESTED ; VI / R e " M /n p , F VA <br /> � FI <br /> COMMENTS: D <br /> �q q CO ONLY <br /> rMFNT <br /> ACCEPTED BY : /J + / EMPLOYEE #: DATE: <br /> ASSIGNED TO : , 4 EMPLOYEE #: DATE: !^/� <br /> 02.0 <br /> Date Service Complete (if alrdady completed): — SERVICE CODE : 21 f P 1 E: 23� � <br /> Fee Amount: 549Amount Paid /S , (�(� Payment Date / 3 e <br /> Payment Type ' - Invoice # Check # JS51( D75Y Receive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />