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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 /> K'J S`J t6 CJS �LA �_ CHECK If BILLING ADDRESS <br /> FACILITY NAME C� ^ ^ <br /> SITE ADDRESS Y V\ \ 3� <br /> �O <br /> KJ Street Number DirectiC on Street Name Cit Zi Code <br /> HOME or MAILING AD`DrRESS (If Different from Site Address) , <br /> �7 /7.3 Ll 'v Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> 7A� °v 32 Sco 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:�� �; � � L� � DATE: <br /> PROPERTY/BUSINESS OWNER MQ( 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 inf ation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: l t/ O <br /> CE '10�-����e H , R9 <br /> c 1 <br /> pM�vo �y <br /> gRTMF r <br /> ACCEPTED BY: nh EMPLOYEE#: DATE: <br /> ASSIGNED TO: h EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 3 `Z� SERVICE CODE: U f P/E: I CIO 2 <br /> Fee Amount: 1 Amount Paid �S,Z. Payment Date Qj <br /> Payment Type'Ti Invoice# Check# D 3336o Receibed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />