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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/OPERATOR. <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME n t I (I 1 ( 1 <br /> SITE ADDRESS L l (�G �1 a� " � Srj o <br /> 4%) Street Number Direction Street Name CI 2io Code <br /> HOME Or MAILING ADDRESS (If Diff nt from Site Address) (J� C n <br /> NV M (A- Street Number '\v M Stmt Name V <br /> CITYSTATE ZIP <br /> r� )a ClSI <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 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 /> also certify that I have prepared this application andth t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATE and FEDE laws. <br /> APPLICANT'S SIGNATURE: �t DATE: rt} a V ►A <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 /> t0 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. J �J P ]' <br /> TYPE OF SERVICE REQUESTED: i 71 /�//���, 14 et) <br /> �• <br /> COMMENTS: S NOV Orr) <br /> AN j 2814 <br /> � �gQur <br /> HEq�N 1174��� Nry <br /> M' <br /> ACCEPTED BY: /t],` EMPLOYEE#: DATE: <br /> ASSIGNED TO: G Zl� EMPLOYEE#: DATE: <br /> Date Service Completed (if alread ompleted): SERVICE CODE: Cj -��: PIE: 2 7 Q <br /> Fee Amount: � 7 -------- Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />