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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> iz 10T' ��0�� � �, 9 0 0 7lqr V I <br /> OWN R/OPERATO <br /> ,�� � CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NA Lef <br /> SITE ADDRESS 2 t y oscrv\l Vr_ V (v\fjlVA+-�Ccc A. S33 - <br /> Street Number Direction Street Name Cft Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> // L\ T IQ l <br /> Street Number Street Name <br /> CITY STATE ZIP / <br /> L(/` � 0 <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> (.7b4 � - 5q 16 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> C <br /> BUSINESS NAME PHONE# ExT. <br /> WlPr A/LA <br /> HOME or M/{]LING ADDRESS FAX# <br /> I L a ( > <br /> CITY SC STATE i1 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <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 provided to me Or <br /> my representative. g� <br /> TYPE OF SERVICE REQUESTED: C r ID1/l` ��/\ <br /> VED <br /> COMMENTS: cu"'1 �V`�'l..� OCT 3 V/} <br /> zoos <br /> S,qN J I UIN CAtO <br /> NDN HDE gEN ErTAL 7Y <br /> ACCEPTED BY: /1�/ EMPLOYEE#: DATE: I` - <br /> ASSIGNED TO: f SW .1 W 1 i1 G EMPLOYEE#: DATE: - 0-2 <br /> Date Service Completed (if already completedy' SERVICE CODE: �� PIE: t C2 <br /> Fee Amount: 1 C5-2Amount Pai f�a,00 Payment Date <br /> Payment Type I Invoice# C ck# 771 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />