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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> kee cuc r C.l«,�,.� �` 0006, <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY A'1 Z ll SA STATE` ZIP 9 <br /> PHON #. EXT. APN# LAND USE APPLIrt.. ION# <br /> (gl ) /L - Z g c)3 <br /> PPHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOIR1 <br /> ( 4 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME CCC PHONE# EXT. <br /> 7 �G 8.)w 3, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �yyG STATE <br /> Cgr >_ ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 applicatio an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT F6tRAL I <br /> APPLICANT'S SIGNATURE: DATE: Z l S <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: J-0001 C/"w <br /> COMMENTS: <br /> 11��cO i✓Y��"Ol4�,� o� e���prr�r�-� cif� - ��,�-l��P> cr c,l l <br /> JJ �"C,�lli�i�lJ' L✓lfti (�Jrin'ifior>l/ r1c4,1e <br /> >�� �P � <br /> ACCEPTED BY: EMPLOYEE#: DATE: </A F <br /> ASSIGNED TO: EMPLOYEE#: DATE: C�1y/I-5J <br /> Date Service Completed (if already completed): SERVICE CODE: O( i P I E: <br /> Fee Amount: �0 00 Amount Paid 4Z&,D . Payment Date <br /> Payment Type Invoice# Check# Ii;— /03 Received By: <br /> UU--, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />