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pp � <br /> 4 � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4bbaIo `d�',F--0t-7-7 $iS 9 <br /> OWNER/OPERATOR f� - <br /> --7 }ice` I CHECK If BILLING ADORES _ <br /> FACILITY NAME ! �J i j <br /> SITE ADDRESS OG�C L`ll N ��)07 <br /> i <br /> reet NumC Nam <br /> ber Direction Street e CI Zi Code i <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( C) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION 004E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> U CHECK if BILLING ADDRESS <br /> BUSINESS NAME C� �O s I a�� /✓ PHONE# Z Ems• I <br /> �j Q { <br /> HOME or MAILING ADDRESS FAX# <br /> -�- z e n yi;s Ar ( ) <br /> CITY STATE ZIP 4S-3 <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE aV FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 iQ... I <br /> PROPERTY/13USINESS OWNER ff OPERATOR I 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, 1, 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 prp*t�om�e or <br /> my representative. d� `dh/r�JC <br /> TYPE OF SERVICE REQUESTED: 11 1 v�. <br /> COMMENTS: JUL (t 6 201 <br /> C, P JOAQUIN C <br /> J HEALTH D gRTMEN <br /> ACCEPTED BY: C3 ti� EMPLOYEE#: DATE: <br /> ASSIGNED TO: rFA EMPLOYEE#: DATE: r-7 <br /> Date Service Completed (if already completed): 1 SERVICE CODE: P"-E: ! p <br /> Fee Amount: 1 �� Amount <br /> Paidr �� Payment Date �L 7 <br /> PaymentType Invoice# Check# Received By: <br /> 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />