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G� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST# <br /> co M C'ON U, S or�� <br /> OWNEiR / OP RATOR <br /> Q�7( I CHECK If BILLING ADORES I <br /> FACILITY NAME I VJ V V <br /> SITE ADDRESS N W Gj�^d M O /U �M�l <br /> Street Number Directlan l2 t r�l le� ep �1�� Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) �� <br /> QX �? lJ Street Number Street Name <br /> CITY STATE ZIP <br /> u o G A <br /> PHONE#t Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> /I /� I / ^ � AnK\DCHECK If BILLING ADDRESSABUSINESS NAME ( /P,,4 7t "-t PHONE# EXT' <br /> C 1 , 1L2 c .1zo0P h 3 <br /> HOME or MAILING ADDRESS FAx# <br /> �o o D ( ) <br /> CITY ' ,^ O61< STATE rA <br /> 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 /> 1 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 n FEDERAL IaWS% . <br /> APPLICANT'S SIGNATURE: DATE: 3 Z ,z <br /> PROPERTY/BUSINESS OWNER❑ OPE ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT t✓ <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 t0 me Or <br /> my representative. PAVA <br /> TYPE OF SERVICE REQUESTED: /v ,/��P�-) / y /Il (f R NT <br /> COMMENTS: 49 <br /> 1 <br /> SAN tS 2 <br /> ,J0N �Co <br /> Fpq Nr,� T� <br /> ACCEPTED BY: t� yG EMPLOYEE M DATE: /� T <br /> ASSIGNED TO: &P-4 �, 04 EMPLOYEE#: DATE: /� Z <br /> Date Service Completed (if already Completed): SERVICE CODE: / P I E:2-30,�5 <br /> Fee Amount: �✓3(� �� ` Amount Pai 3 �U Payment Date 2/ <br /> Payment Type �.�— Invoice # Check# / 2 8,3(Ft31 Re ived By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />