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"JOAQUIV96nUNTY ENVIRONMENTAL HEALT WKEPARTMENT <br /> 7 SERVICE REQUEST <br /> Type of Business or ,10 k FACILITY ID# SERVICE REQUEST# <br /> * (ZIL Z: �X& 5a= <br /> OJVNER/OPERA OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> SITE ADDRESS 1 Oj J—S6(`7�,- <br /> ® Street Number Direction 4Lh lig ree artf��L b i Code ` <br /> HOME or MAILING ADDRESS f Different from Site dress) <br /> G Street Number Street Name <br /> CITYSTATE ZIP <br /> tLA_ t� Ci <br /> r <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> Q)_09 &J -- <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> -�--�- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU TOR L CHECK if BILLING ADDRESS❑ <br /> t -!�' / 7 <br /> BUIN- NAME PHONE# EXT. <br /> 7.,2 <br /> Hopp O(r3MAILl ADDRESS FAX# CZ <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 /> 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 /> Ir <br /> APPLICANT'S SIGNATURE: �-e�� DATE: tQ 12 6g <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or' environmental/site assessment <br /> information to.the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: !L�� ,/� CJd cL G <br /> COMMENTS: `` �E�E��` RECEIVED <br /> G Wr----� n ; 18 2uv� APF 2 2 2008 <br /> SAN JOAQUIN COUNT( SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> 77 <br /> Date Service Completed (if alrea completed : SERVICE CODE:,.. ' PIE: <br /> Fee Amount: G' Amount Paid �' Paym nt Date Z Z - <br /> Payment Type Invoic ,✓� 5 VAb� Check# Received By: <br /> EHD 48-02-025 7 SR FORM(Golden Rod) <br />