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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 1 OPERATOR ft I � � 1 CHECK if BILLING ADDRESS <br /> r�_ ---- <br /> FACILITY NAME / <br /> It <br /> SITE ADDRESS " � ,J; doe f . ' '� ' fj �'� " d 4L <br /> Street Numher Dr o cion r /�� r' •�reet N'dihe � � �I� � � � <br /> Zip - fi � <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Numbnr Slrecl Name <br /> CITY STATE ZIP <br /> PHONE #1 Exr. JAPN # =USECATION # <br /> J <br /> ( 415 <br /> PHONE #Z F_xT BOS DISTRICT LOCATION CODE <br /> _ CON '! ' R_ ACTOR / SERVICE RE ( UEtSTOR _ <br /> REOUESTOR r r CHECK if BILLING ADDRESS <br /> EXT. <br /> susiNEs3 NAME PHONE #--- � � r �✓it �c" 3 _. <br /> FAX # - <br /> HOME Or MAILING ADDRESS , .� +-� 1 l fZD <br /> CITY STATE % ZIP <br /> BILLING ACKNOWLEDGEMENT: 1 , the undersigned property or business owner, operator or authorized/agent of same , <br /> i3rknowledge that all site and/or project specific ENVIRUNMCNTAL HEALT'ti DEPARTMENT hourly charges associat,Id with this project or <br /> activity will be billed IU me or my business as identified on this form . <br /> I also certify that I have prepared this Ipplication and that the work to be performed will be done in accordance. with all SAN Jr ,AQUIH <br /> COUNTY Ordinanre Codes , Standards , S -A I rI an,d FEDERAL laws. <br /> APPLICANT ' S SIGNATURE : IJ DATE : ! _ <br /> PROPERTY I BUSINESS OWNER-- OPERATOR [ MANAGER ❑ OTHERAUTHORIZEo AGENT CI �� / G ( �' C,c✓ <br /> ItAPPLICANI- is nol theBicuNGPARTY proof of authorization to sign is required � 'frrle <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner of operator of the property located at trio above <br /> site address , hereby authorize the release of any and all rosults „ geotechnical data and/or environmental/site assessment information <br /> to lho SAN .10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available and cat the same tirne it is provided to me or <br /> my representative . QP <br /> TYPE OF SERVICE REQUESTED : ��,JO� �j� �f� '� f (�` � Sf��l f ��j ����f " ` 11iWg;� <br /> COMMENTS: OPEC 19 2 <br /> SAN JOAQUI <br /> N 021 <br /> HOI "`1 T U1w .& L pREL <br /> FNT I <br /> ACCEPTED BY : p . Em?LOYEE #: DATE: <br /> I L : VA 2 l l <br /> ASSIGNED T0 . r/J D � EMPLOYEE #: DATE' L 2 <br /> Date Service Completed (if already completed) : - SERVICE CODE: 612 PI E: 23411 ' <br /> Fee Amount : / Z%� /� � - Amount Paid 4 -� Payment Date <br /> Payment Type Cam Invoice # I�ectf' � eceived By: <br /> ULTLJ� <br /> FI-ID 48 -02-025 SR FURM (Golden Rod ) <br /> 07{17/08 <br />