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8r 0 ; �)_4 3q <br /> SAN JOAQUi,J COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br /> SERVICE REQUEST <br /> Ty a of Busin ss or Property FACILITY ID# _ SERVICE REQUEST# <br /> C A fA X01 l � <br /> OWNER/OPERA R <br /> CHECK if BILLING ADDRESS <br /> FACILITY)VAME <br /> SITE ADDRESS <br /> Street Number I Direction C(A ` !C YA S r Name •-F - Ci Zi Code <br /> HOME Or MAILING ADDR/E�SS (If Different from Site Address) <br /> 2(6 3 C " I S J • Street Number Street Name <br /> CITY STATE ZIP <br /> 1') a GI 5 Z� <br /> PHONE#1 ( EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V UI Wy, <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> Z LLw � S <br /> C TYt CC 4 A-J� T STATE ZIP /i 0 <br /> BILiLING 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,STATE and FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE: W' 3 r- Y--1 DATE: 2 <br /> PROPERTY/BUSINESS OWNERta� OPERATOR/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 isy'�J�d to me or <br /> my representative. boil- '1 JA's <br /> TYPE OF SERVICE REQUESTED: n Vtltoda <br /> COV <br /> COMMENTS: <br /> %4'/0 ?419 <br /> yNT/rf HpA'I,SIV <br /> RSI yFNT <br /> ACCEPTED BY: ti EMPLOYEE#: 0 DATE: <br /> ASSIGNED TO: [,' EMPLOYEE#: DATE: '7 <br /> Date Service Completed (if already completed): SERVICE CODE: P I" <br /> Fee Amount: ( Amount Paid Payment Date <br /> Payment Type 'i Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />