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SAN JOH ..,IN COUNTY ENVIRONMENTAL HEAL-1 n DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> UY>' / Fo -2o06 ck 0o-?Y L4 <br /> OWNER/OPERA OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS � j pl r J`(1 U U'n <br /> S1-3, <br /> reet NuLl Direction `/L \ St`re�et`Name C' Ci V\ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE# EXT. APN# f� LAND USE APPLICATION# <br /> �� <br /> (2A) 7`�`���� 1 l 3003 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (�� U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME P EA �. ` EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 SIGNATOR y���7(�� u �CQQjr Ce& DATE: 1 c ` 12�l <br /> PROPERTY/BUSINESS OWNER 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 assessorInformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pLI�V, e or <br /> my representative. •p� �1�1►`/C <br /> TYPE OF SERVICE REQUESTED: I—��L� C�✓1 l-kN �n� V� <br /> COMMENTS: <br /> H�4A'�iRo C <br /> Ty 0 p�R���ry <br /> T <br /> ACCEPTED BY: Ml EMPLOYEE#: DATE: I �_ 1_ 17 <br /> ASSIGNED TO: )A LA v)h l EMPLOYEE#: DATE: - l -I 7 <br /> Date Service Comp eted (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: L9 0 Amount Paid �S U(� Payment Date /-2// ' <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />