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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br /> SERVICE REQUEST <br /> Ty e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW ER/OPERATOR <br /> j � <br /> 7'11 C"�.N `� •'�� CHECK If BILLING ADDRESS <br /> ` <br /> FACILITY NAME - r <br /> �SITE <br /> .�ADDRESS <br /> 1 �.J ) Street Number Direction �— _ Street Name —F t'—tV ciit 'Zi✓CC—ode <br /> HOME <br /> �o[r�MAILING <br /> ADDRESS (If Differen f�roem Site Address) <br /> V�p �,•, �l� ���—\� Street Number Street Name <br /> CITATS ZIP <br /> TY LCI k ty Z-1 0 <br /> P (�(# EXT. APN# LAND USE APPLICATION# <br /> �I�;;1 <br /> P N tit EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `c` V PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 /> 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 STATE a d FEDERAL laws. C_ / c <br /> APPLICANT'S SIGNATURE: DATE: �s (p ' �O� t <br /> PROPERTY/BUSINESS OWNER OPERATOR/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&j/iLded to me or <br /> my representative. I'' I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: VG <br /> FN�N'Y <br /> R�FHT <br /> ACCEPTED BY: �� i,r EMPLOYEE#: 597`7) DATE: 7 A <br /> ASSIGNED TO: "w EMPLOYEE#: �17DATE: //� <br /> Date Service Completed (if already completed): SERVICE CODE: oti PIE: /n <br /> Fee Amount: 9ls-G• 0� Amount Paid /s�-�� Payment Date <br /> Payment TypeJT/ Invoice# Check# 6 D 7�� g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />