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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE EST# <br /> OWNER/OPERAT <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ��,,,� j,�eyA cl\, v)VA(VLO y}� <br /> SITE ADDRESS 1—r �j 1 t�11 Vii"1 cis Z(� <br /> Street Number Direction Street Name cityZi Code <br /> HOME f Or MLIt-NG ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STAT ZIP q5 2- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# `''�� <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C1'-J-LZAJ "V Y2A Got v CHECK if BILLING ADDRESS <br /> --> EXT, <br /> BUSINESS NAME ui:- l CA1 e� L� 00—A(V-1 <br /> PyQN <br /> HOME or MA LING. DppRESS FAX# <br /> 9t"Di <br /> CITY �y1" .. `, STATE �Q, ZIP �S <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 /> 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: �� I �� icG'n DATE: Cil <br /> PROPERTY I 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 assessmePc <br /> rc nation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS r <br /> my representative. p •rr <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JO 20� <br /> CyoUN <br /> gRTM Nr <br /> ACCEPTED BY: �r1�. 1[>t� EMPLOYEE#: DATE:( -tL <br /> ASSIGNED TO: n EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I �C5 <br /> Fee Amount: L OD Amount Pai �J D� Payment Date <br /> Payment Type .•7 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />