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J <br /> J <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br /> SERVICE REQUEST <br /> Type;f Business or Property FACILITY ID# SERVICE REQUEST# <br /> O7R/OPERATO <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME C� ( \ V�1 t V <br /> SITE ADDRESS /�/ iJ ' T 'p'. X� �G y5�el'Z <br /> Street Number Direction Street Name Cit Zin Code <br /> HOME AILING ADDRESS (If Different from Site Address) <br /> r l/\ Street Number Street Name <br /> CITY STATE ZIPE�2-/ Z <br /> L CWC f <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R <br /> LIES TO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> r C �-S �r <br /> HOME Or MAILING ADDRESS S r' / 2^, / FAX# <br /> CITY �Gu Ce L STATE ZIP <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 / FEDERAL laws. <br /> APPLICANT'S SIGNATURE:X DATE: <br /> PROPERTY/BUSINESS OWNER❑ / OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> It 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. w1 <br /> TYPE OF SERVICE REQUESTED: aS 7- <br /> COMMENTS:COMMENTS: �EC <br /> FEB 2 � 2p12 <br /> QUIN COVN� <br /> SA EN��R pEPAP�ENT <br /> NE-p,L� <br /> ACCEPTED BY: J n EMPLOYEE#: DATE: <br /> ASSIGNED TO: ���CiH t r EMPLOYEE#: 142-2— DATE: �/Z l //3 <br /> Date Service Completed (if already completed): SERVICE CODE: � PIE: ),-�)o& <br /> Fee Amount: 75-0 oc) Amount Paid c� 7S 2 /-3O , D Payment Date 7/ � <br /> Payment Type I Invoice# Check# Received By: <br /> " -J� D 2-1�g <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />