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o 4a-j,o <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATORI, <br /> n CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 ' <br /> c Ctiu <br /> SITE ADDRESS <br /> ?S&&er Direction V Street Nam Ica aq <br /> �Zi Code Y <br /> HOME or MAILING ADDRESS (IIftDifferept from Site Address) <br /> Street Number Street Name <br /> CITY STATE C /� ZIP <br /> �Yccl.+-t�trfiJ <br /> / <br /> EXT. <br /> APN# LAND USE APPLICATION# <br /> PHONE#2 S Exi• 130S DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR {{{��/ <br /> I y t � /Jn�j CHECK If BILLING ADDRESS <br /> BUSINESS NAME n IAN <br /> U S�l PH NE fig EXT, <br /> HOME OrZMAILING ADD �� FAX# <br /> CITY �C STATE ZIP <br /> BILLING ACKN WLEDGEMENT: 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 identifi 0 on this form. <br /> I also certify that I have prepared this application n 'that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ti rie <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 prA:NWPcd to me or <br /> my representative. Irk r <br /> TYPE OF SERVICE REQUESTED: e/V <br /> pi <br /> COMMENTS: <br /> SgNIQ <br /> dOq 1l2®f9 <br /> ElyQUI <br /> HSL Hoo pMoNT t <br /> tTA��ti7- <br /> ACCEPTED BY: w.— EMPLOYEE#: DATE: Iq <br /> ASSIGNED TO: `/1 n EMPLOYEE#: DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: 3 I E:!�� <br /> Fee Amount- Amount Paid �SLo O� Payment Date /7 q <br /> Payment Type Invoice# Check# GIG Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />