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SAN JOAQLTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines or Property FACILITY ID# SERVICE REQUEST# <br /> X260 70°/�le� <br /> OWNER I OPERATOR <br /> Q CHECK If BILLING AoORESSEI <br /> FACILITY NAME SR\) C OK) ^J tp <br /> SITE ADDRESS (i2,0 SIG w \iGS2ynjt OtV2 I 9S334- <br /> Street Number I Direction I Street Name f city_ ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2�-g --7 Po I 1 O C..L. <br /> i Street Number Street Name <br /> CITY E STATE __ ^^ ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. SOS DISTRICT LO,,C��.A.,�T,,IO11N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n I 1_ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> Sov la `-73 L-t <br /> HOME or MAILING ADDRESS FAx# <br /> 22-8-1 ell, c ( ) <br /> CITY AAQYLV I a/, STATE C-4 ZIP S t7� <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATUREDATE: 11 11 D I <br /> PROPERTY I BUSINESS OWNER 13 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT a5 Soon a5 It Is available and at the same time It Is provided to me or <br /> my representative. Pr/� <br /> TYPE OF SERVICE REQUESTED: s ECS <br /> COMMENTS: - <br /> NOV p 7 P014 <br /> SAN JOAQU/N <br /> HEq rH DE <br /> PA -WC <br /> If <br /> ACCEPTED BY: EMPLOYEE#: DATE: W-7 ' <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: C <br /> Fee Amount: Amount PaiaF, <br /> O D Payment Date <br /> Payment Type Invoice# Check# Fec ived By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />