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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 /> , - �, /��„ /„I��t� _ v� A'mn <br /> � CHECK If BILLING ADDRESS <br /> G/ FA(CIL�IT,e�CMiE � G��� (it�lV�+ <br /> S TE AD(DRESS �� I 11_ I )l / � <br /> S reef umber Direction lT W� str¢et Name C ZipCode <br /> HOME Or MAILING ADD{R�}E-S�IS.�(If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> e-- REQUESTOR I/ ' 'sw 6�?>l CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME \ (SI �• C SU PypNE# �Z_ ' C Exr. <br /> 6 <br /> HOME MAILINGADDt2ESS FAX# <br /> CITY STAT ZIP G� �-Z / <br /> BILLING CKNOWLEDGEMENT: 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, ST TE and FE FmL laws. <br /> APPLICANT'S SIGNATURE: DATE: �iJ <br /> PROPERTY/BUSINESS OWNER❑ IteBILLING <br /> OPERATOR/ AN GER ❑ OTHER AUTHORIZED AGE O�(J j%� <br /> If APPLICANT IS noPARTY, roof of authorization to sign is requir d Tirie <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at,;e ove <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme p;af tiol� <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pro e" _ <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: VV Q� N i�to- <br /> COMMENTS:. r � �-�' � / 46�Q <br /> ec Cc1N <br /> ACCEPTED BY: EMPLOYEE#: DATE:2-10-D �O <br /> ASSIGNED TO: i ( J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 3 0 L-t Amount Paid L� Payl.,-..L--L- <br /> Payment <br /> a«Payment Type V Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />