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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property r FACILITY ID# ER,,} <br /> LVICE REQUEST# <br /> 6 I�U m <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME .^ vG <br /> L W}5 U fit LL <br /> SITE ADDRESS G -I Wt (�'�� <br /> 7 7 Street Number Direction I I�L $4reet Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> L G E W O Street Number Street Name <br /> CIT LA STATE ZIP _ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ('Y� &OZ- -7y9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Z i�—, ('(A- <br /> ( .ft— In CHECK if BILLINGADDRESSE] <br /> BUSINESS NAME l l'� (/� PHONE# _ Ex,. <br /> 2OZ <br /> O, E or MAILING ADDRESS FAX# <br /> CITY STATE ZIP C.''5 3G <br /> BILLING A KNOWLEDGEMENT: 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 YFEDEL I L' DATE: _ <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY I BUSINESS OWNERIJ��,I( OPE TOR/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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Isjy d to me or <br /> � <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: �� JkAZ"C�� <br /> COMMENTS: July <br /> N p <br /> �p25sgvjOqINNFijT" ON41, CO?U0t.4 <br /> �9 <br /> �Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 2�j <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE: <br /> Fee Amount: I L� Amount P S�00 Payment Date 2 <br /> i <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> "�,s�3 S <br />