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SAN JOAQU... i�OUNTY ENVIRONMENTAL HEALTH G-. ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Coac( C':z,e.� FA-06�3(n�l g —bZ 0b 7 "-7 5 <br /> OWNER/OPERATOR X14 <br /> ,�CC/� CHECK If BILLING ADDRESS iL'7 <br /> FACILITY NAME y- <br /> SITE ADDRESS <br /> Street Number Direction Street Name ,��qI cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) q0 N S ��.G�+���rU '414L <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Cao q T 20x1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZL�) c0(�z -vyloQ 37 b <br /> PHONE#2 EXT. BOS DISTRICT I LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 G� F—C.C-I-es CHECK If BILLING ADDRESS <br /> BUSINESS NAMEY �` PHONE# i' EXT* <br /> a <br /> HOME or MAILI G ADDRESS nn FAX# <br /> 6 > ( ) <br /> CITY STATE /7 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 /> aiso 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: - DATE: 'I J <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 assessm t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is pe Or <br /> my representative. R M1- <br /> TYPE OF SERVICE REQUESTED: 01) y <br /> COMMENTS: 1 <br /> �/1A�✓L�- ©� Q u.)��- �ca�-}-� �rhr pF M FH�H�Y <br /> RT,yFHT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: LD -.sEMPLOYEE#: DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: Q <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 />