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a <br /> e <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN4 <br /> —R SERVICE REQUEST <br /> Type of Bus ess or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> •— n I '� r�• ��`^�� ` , CHECK If BILLING ADDRESS <br /> FACILITY NAME a <br /> SITE ADDRESS �32-Z L r� (� of C'Z0-1 <br /> Street Number Direction r t.Name city Zi Code 10- <br /> HOME <br /> HOME or MAILING ADDRESS (If\Different from Site Address <br /> L 1-\� U ��, y t Street Number I Street Name _ <br /> CITY STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> PHONE 42 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR p�7p <br /> •, �VAhCHECK if BILLING ADDRESS L� <br /> BUSINESS NAME `—�/` P NE# EXT. <br /> HOME Or ME,ILING ADDR SS FAX# <br /> CITY C_.C�v 1�� STATE V ZIP 61k C--1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site anG/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> a^tivity will be billed to me or my business as identified on this form. <br /> U!so certify that I have prepared this application and that the work to be perfoirned will be done in accordance with all SAN JOAQUIN <br /> :o i Y Ordinance Codes, Standard::�Tn-TFEo E laws. q <br /> APPLICANT'S SIGNATUR • DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGI OTHER AUTHORIZED AGENT ❑ p <br /> If APPLICANT is not the BILL WG PARTY,proof of authorization to sign is requ red Title <br /> ALITHORIZATIC 4 TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prope ty locatQd 21 Lhe above <br /> site addresst, V4by authorize the release of any and all results, geotechnical data and/or environmental/site assessd�i'' y l W <br /> �W <br /> %, Ms UIN"OUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time it is (F�� <br /> yN , I0 IWds <br /> ULI 14 <br /> OF SERV EQUESTED: �. Q� �Gt.� � G ���[p/� !°G' �01 <br /> �J SAr4 JOAQUIN ENVI OMEN q� TM <br /> HEALTH pFpARTME T <br /> I <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: , W EMPLOYEE#: DATE: ' (S <br /> Date Service Completed (if already completed): SERVICE CODE: �� PI E: 4jp i <br /> Fee Amount•' 1 q!� d Amount Pall 3 [ G - 1%� D Payment Date S <br /> Payment Type Invoice# Check# !bv cel d By: <br /> EHD 48-02-025 I� SR FORM(Golden Rod) <br /> 07/17/08 <br />