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SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH r' 'PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 41 "ki i �2'-�< S la 1 C7 <br /> OWNER/OPERATOR <br /> f �� CHECK if A ING ADDRESS <br /> vl i I'ZAL ut v" k CIA <br /> FACILITY NAME <br /> ` 1 <br /> SITE ADDRESS6" 06ioa; <br /> 1 <br /> Street NumberF.". Von I treat IC.. CI Zip Code <br /> HOME or MAILING ADDRESS (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 /> f ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINE S AME / PHONE# EXT. <br /> /A �A C 6014 Z ! 1 I A�1 c)L <br /> HOMI O ,Mp�LING 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 /> 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 X/ DATE: <br /> PROPERTY I BUSINESS OWNER 0] / OPERATOR I 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 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: }-- <br /> COMMENTS: i b <br /> ty-,at L 1 C �ti�'rC�� '5 C e e�� 9'/ f cvi��' ��/I'AAR 1 <br /> s 7r/� 5 C.'��ti, l <br /> �— }C, l A, <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ ] J <br /> ASSIGNED TO: EMPLOYEE M DATE: 5 / /w <br /> Date Service Completed (if already completed): SERVICE CODE: �I�{ PIE: 1c� <br /> Fee Amount: G�CJ l Amount Paid3c)b X70 Payment Date <br /> Payment Type Invoice# Check# S�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />