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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F-A - Q '�)Klbb 7 <br /> 3 <br /> OWN /OPE TOR <br /> A ,��� ►� I ..../� CHECK if BILLING ADDRESS <br /> FACILITY NAME ` lA(, ^V <br /> SITE ADDRESS r -J 15 1 <br /> Street Number Direction Street Name Cit ZI Code <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 /> ( ) G oU7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Ab <br /> PHONE Ems' <br /> HOME or MAILING ADDRESS - FAX# <br /> CITY Cin �4 STATE �{� zip q Vttol`, <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. r <br /> APPLICANT'S SIGNATURE: �Q� -'�• �clL{.,�� DATE: It� �"� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C1 k-k(yy�tC 6 � V <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 IS provided to me Or <br /> my representative. <br /> PAYM <br /> TYPE OF SERVICE REQUESTED: i T� �t®in RENT '" <br /> COMMENTS: AUG 2 5201/ � <br /> $AH JOAOUFNM7Y AU U 2 1 1017 <br /> ENVIROhMENTA <br /> AEALrH DEPARTVEM <br /> "dLI H <br /> ACCEPTED BY: QQ,wk EMPLOYEE#: qDAT <br /> ASSIGNED TO: -ftof O ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already co Ieted): .4 1SERVICE CODE: i� 22 PIE: <br /> Fee Amount: JI �� Amount Paid S(a 0� Payment Date S.�S <br /> Payment Type � Invoice# Check# �D3 b Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />