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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 /> ^ CHECK If BILLING ADDRESS <br /> FACILITY cus <br /> SITE ADDRESS !'e--Fr\r/Y <br /> Street Number Direction � 11reem'e ' `� •Jt L/CIIJL�IU r \ Z11 Cotle <br /> HOME or MAILING ADDRESS (If Different from-Site Address) 1I O CL <br /> Street Number <br /> CITYC ^ StTf-7 A._ ZIP <br /> PHON 1 1' 1 EXT APN# LA NO USE APPLICATION# <br /> 314 ' 3 �-oZ <br /> HONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK It BILLING ADDRES <br /> fG/ BUSI ESS AM p I �3 ExT. <br /> t rZ� <br /> HOME Or MAILING ADDRE FAX# <br /> del Ln I I ) <br /> CITYr4nn STATE - ZIP U W <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, StandardW,STATE and FEDERAL laws. <br /> / W ( l (J <br /> APPLICANT'S SIGNATURE: �� DATE: <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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: AD <br /> ✓�H 0 <br /> �u,,o 7p1 <br /> H p q/NCO <br /> TND PMA N! )v <br /> f AR <br /> ACCEPTED BY: cY A r4 EMPLOYEE M DATE: to <br /> - 1 <br /> ASSIGNED TO: F-7-d C,h-LLN-M1 EMPLOYEE#: DATE: o -/ <br /> Date Service Completed (if already completed): SERVICE CODE: O�j PIE: O <br /> Fee Amount: 1 G,:;)� Amount Paid 1S,,O0 1 Payment Date 4 <br /> Payment Type LO Invoice# Check# 2-2--7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> C&C4'4'� <br />