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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 /> �.00A,V/A CHECK if BILLING ADDRESS <br /> FACILITY NAME � l <br /> SITE ADDRESS I »c �- Ao <br /> Street Number Direction l.lJ Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> MCI) S ISDOIL-0 JZ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSIN, j _` � ' PHONE# — 1 EXT* <br /> �,- `IJV" <br /> HOME MAILING ADD ESS FAX# <br /> CITY Y-k STATA, ZIP �1 <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: ��µ�— DATE: <br /> PROPERTY/BUSINESS OWNE ;snot <br /> O OR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT the BILLING PARTY,proof of authorization to sign is required l i II � 'o r <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locat the�ll� <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses it I fmation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time,%lb,provided�b! V <br /> my representative. E ✓OqQIJ <br /> TYPE OF SERVICE REQUESTED: CVACk Yla Q 0-�: sa Wk <br /> COMMENTS: NT <br /> bouu K+ ek 5>J'-\0'0 c jJ <br /> \a( 1;6V.S\ r e SS <br /> ACCEPTED BY: IV,0 V\0,V�D EMPLOYEE#: DATE: u _I�� <br /> ASSIGNED TO: _!� i2AVVkEMPLOYEE#: DATE: -l-1l <br /> Date Service Completed (if already complete . SERVICE CODE: OW l PIE: Ivo Z <br /> Fee Amount: l�2 Amount Pai /6� Payment Date <br /> Payment Type Invoice# Ch ck# C xma-n34 IReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />