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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 / , /(/f� I� <br /> CHECK If BILLING ADDRESS LJ <br /> FACILITY NAME Q a / / A <br /> SITE ADDRESS <br /> Street Number Direction L Street Name CI Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> I ) 2-0--21 5W9 <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �® nn / <br /> A CHECK If BILLING ADORES <br /> BUSINESS NAME — PHONE# SExT. <br /> Zs' S�/� '3 3 <br /> HOME Or MAILING ADDRESS 4��FAX# <br /> J=am" <br /> CITY A✓��r /G, 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 /> 1 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 aV FEDERAL laws. <br /> APPLICANT'S SIGNATURE: —teQ/J G DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: V�C(X� <br /> COMMENTS: <br /> C-u,)n ShI � PeR`� coo` <br /> SPN�NOY �tom'" <br /> ACCEPTED BY: Led rz� EMPLOYEE DATE: <br /> yr <br /> ASSIGNED TO: N1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): . SERVICE CODE: PIE: / a. <br /> Fee Amount: ti �^�' Amount Paid lx) Payment Date `t 1-2-CR 1(o <br /> Payment Type I`'rt Invoice# Check# $ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />