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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �> o b�yd s <br /> OWNER I OPERATOR <br /> X R L✓A I_4_--, CHECK If BILLING ADDRESSO <br /> FACILITY NAME . f�/ <br /> n <br /> U C,L <br /> SITE ADDRESS //► /�/�/ (/ry�� / <br /> L Street Number Direction I �� Street Name" v — !Zi Cod✓e <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 /> (�00 ys-, s3 0 C- <br /> PHONE#2 �' EXT. BOS DISTRICT LOCATION CODE <br /> ( ) �O G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOI�—� be r) fng a k? CHECK if BILLING ADDRESS <br /> BUSINESS NAM tn�llA PHONE# EXT. <br /> HOME Or MAILING ADDRE I '49D (AX# ) <br /> CITY _ -�1 �1— STATE ZIP G c/ <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,STand FEDERAL I ws. <br /> APPLICANT'S SIGNATURE• DATE: <br /> PROPERTY I BUSINESS OWNER OPERI T R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT xSot the BILLING PARTY_proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assess t'nformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS;g " �Or <br /> my representative. ," <br /> TYPE OF SERVICE REQUESTED: VIVA— C <br /> COMMENTS: S,qN JO Zo�, <br /> U .# �� I Enly/AQUI C <br /> h�CTy pM�.At ry <br /> T <br /> ACCEPTED BY: EMPLOYEE#: 'rJ 3 DATE: //-7 //-7 <br /> ASSIGNED TO: ��,� ^ p EMPLOYEE#: G_ �DATE: )/ 7 f <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> PIE: D <br /> Fee Amount: 'C;J� �,o Amount Paicq z) Payment Date t 7/ <br /> Payment Typ Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />