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SAN JOAQ-4 COUNTY ENVIRONMENTAL HEALTh . EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> f7t\, CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> $I <br /> TE ADDRESS n <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Ntuber ����-•-�� Street Name <br /> CITY � ,^\ `` STATE �fA ZIP 1 - <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2t,c 1462 CO2 <br /> PHONE#2 6 EXT. BOS DISTRICT LOCATION CODE <br /> O <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r , <br /> -%�,#'�71�`� \ [ .\ [T , CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 v V GPHONE# EXT. <br /> ku �5 - 2,L<"1 46e-- -71:02 <br /> HOME or MAILING ADDRESS „ r1 FAX# <br /> Z3�fl W '1 ct� LLxc� �� ( ) <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,STA an�FIEo L laws. <br /> APPLICANT'S SIGNATURE:- DATE: / <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to Sigh 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 sessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same tlnffAito rgvided to me or <br /> my representative. �. <br /> TYPE OF SERVICE REQUESTED: t�Pol Un f(,l Kfi 44 A <br /> VF <br /> COMMENTS: f /w UK+W C M N (f-1 h e n S E j101 fr 10 <br /> ?0P <br /> H� TH 0Aft OAQtJ//V <br /> 0z'NTgC TV <br /> MFNT <br /> ACCEPTED BY: // EMPLOYEE#: DATE: 3 U <br /> ASSIGNED TO: i (�L C vl EMPLOYEE#: DATE: IVU I-7 <br /> Date Service Compl ted (if already completed): SERVICE CODE: PIE: IVO2— <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />