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SAN JOAQtt COUNTY ENVIRONMENTAL HEALTH trtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ig-�ot3 7�1� SR oa 7�37£� <br /> OWNER/OPERATOR <br /> SJSOLY\0. al�ou\ CW CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS AI)s Q_ w1f AVt/'� -f-N <br /> Stree[Number I I/ ��• ` • �^'�/.� <br /> Direction Street Name CIN Zin C�tla <br /> HOME Or MAILING ADDRESS (If <br /> ITII piff;e nt from Site(�Addr(elss) <br /> , I V ` Street Number Street Name <br /> CITU eTF TE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> &C9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR •� �1q' <br /> SJS0.1(�!') t YY.� ���� CHECK if BILLING ADDRESS Lei <br /> BUSINESS NAME '\� i�'--1-�R`+` V PONE# ^ _��&6 <br /> HOME or MAILING ADDRESS — - l 1 f V-0 FAX# `1- <br /> CITY +0C <br /> STATE ZIP 67 S'-�Le_j— <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 thisplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TE and DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �� w <br /> ROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titre <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 IS provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: o PAYMENT <br /> COMMENTS: RECIFIVtEF <br /> CS�L� ✓l(�2� © C37.VY1--e� M;-� 0 9 2w`3 <br /> SAN JOAQUIN COUNT <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: LA Vyl <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 40 PIE: DL <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 />