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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 V/1 <br /> / 6'4 e-A 0 CP1 ^��^ / CHECK If BILLING ADDRESS <br /> FACILITY NAME cm <br /> 1n,n , /- n, /^ + „_ /� <br /> SITE ADDRESS /� o�SY1 1 'Cy�vl �I�1�5(e Y ��� <br /> Street Number Direction V Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ; 2� .��� �• <br /> Street Number Street Name <br /> CITY I. {_� V, STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n 1 , n S �� I �, <br /> fU v 1 (,�� G� CHECK If BILLING ADDRESS <br /> P I EXT.BUSINESS NAME C / y'qv '� lXn/ � � <br /> HOME or MAILiG ADDRESS FAX# <br /> CITY G'�f t� — STATE C/\ ZIP C"I Is <br /> T 1 <br /> BILLING ACKNOWLEDGEMENT:II/ ` 1'\ \ I, the undersigned property or business owner, opeVrat_o`r or authorized Jagent11off 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 FFEDERA laws. <br /> APPLICANT'S SIGNATURE: N(I 7 DATE: 1— <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If) S t 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 locat t the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/siiu ®information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the SaIT� � i d to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 1 IT1 <br /> 91 <br /> COMMENTS: C Incn'n� I ��V v Vl�v �\tk I \ <br /> �/ t(/'Y l t/olif" (� o s��O RONoER N�NS <br /> N�`�N OEPP <br /> ACCEPTED BY: 1V\ EMPLOYEE#: DATE: <br /> ASSIGNED TO: C1 11 EMPLOYEE M DATE: l_2 I <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: W�2 <br /> Fee Amount: Al ` �Z Amount Paid Payment Date�� <br /> Payment Type 1 I Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />