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SAN JOAQ OCOUNTY ENVIRONMENTAL HEALTHEP <br /> ARTMENT <br /> SERVICE REQUEST <br /> Type of Bus i ess or Propert FACILITY ID# SERVICE REQUEST# <br /> �6 �1 <br /> 1e i ©, 1 �7 Z <br /> OP l y ON �� CHECK if BILLING ADDRESS <br /> Eyo <br /> FACILITY NAME L1- <br /> SITE ADDRESS (C)-2, t_�` �(��� <br /> Direction �� <br /> Street Number treet Name l ZI Cade <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 /> ( e]) `- r 01� lYJ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (� r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO 00 L eq <br /> . Fa CHECK if BILLING ADDRESS <br /> BUSINESS NAME �/ PHONE# EXT. <br /> E�1-10 LS (5� Ll�3E- <br /> HOMF�or MAILING ADDTq�ip <br /> `S Ct FAX# <br /> J ( ) <br /> CITY Lo STATE q ZIP j <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 /> I 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, TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / h o•- DATE: (S/ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Elif APPLICAN 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 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: � A <br /> COMMENTS: r/\ar� OA—J - <br /> \/J- / ,\O�� ��V`-hc,//�► I JUN 14 20 <br /> �- <br /> V SAN d0 Q 17 <br /> EN /RUiN COMV O <br /> a <br /> /14 <br /> r11D,E AQ MENr <br /> ACCEPTED BY: 1/t — v A tv EMPLOYEE#: DATE: r n ' I /�7 <br /> ASSIGNED TO: I I +'r �/ EMPLOYEE#: DATE: `Y <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E.6 / <br /> Fee Amount: Amount Paid / Payment Date <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />