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I <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> -SERVICE REQUEST i <br /> Type of Dusfness or Property FACILITY ID# SERVICE REQUEST# <br /> 161 Iq <br /> OWNER OPERATOR <br /> M CHEOICIf BILLING Al i <br /> FAciurY NAME I <br /> 8 e u"bet I <br /> 1 /2, IlJStTEADDRESs �� <br /> y 1f �3 <br /> ati <br /> HOME or MAILING ADDRESS (if Different from site Address) <br /> streetNumber <br /> CITY STATE Zip <br /> PNONE#1 EXT. APN iE LAND USE APPLICATION 0 <br /> I ) <br /> PHONE#2 Exr• SOS DISTRICT LocAT(ON CODE <br /> ( i <br /> CONTRACTOR.I SERVICE REQUESTOR <br /> RrQUESTOR �•-���h � CHECKIfBILLiNOADaREs <br /> BUSINess NAME ,r^ PfIONE# ExT <br /> I? y'M d I C• �'�� � � HCl <br /> HOME Or MAILINe ADDRESS >� ,, FAX <br /> CITY ��C+` STAT! <br /> �6r/? /,t+ ZIP <br /> J <br /> BILLING AGKNgWLgDGEK,0_T, !, the undersigned property or business owner, operator or authorized agent of same, ' I <br /> acknowledge that all site andlor 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 appiicatign and that the work to be performed will be done In accordance with all SAN doAQuIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL faros. <br /> APPLIt ANT-*$SIGNATURE: DATE: Z-141- <br /> PROPERTY/ <br /> -141-PROPERTY1 BUSINESS OWNER® - OPERATOR( ER C{ OTHER AuTHoRrzED AGENT CZ <br /> ffAPPhicANr1&not1h9geuNQPAR proof of authorization to sign Is required "fiarte <br /> &THOR(7,,U ION TO RELEASE INF RMATIO :When applicable,1, the owner•or operator of the property�ated at the above <br /> site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/sitV*t Informationto the SAN JOAQUIN COUNTY ENVIRONM ENTAL HEALTH DEPARTMENT as soon as It Is available and at the same 0to me or j <br /> my representative. '6'.0 <br /> /� <br /> TYPE OF SERVICE REQUESTED: ! 1 V4P1 , <br /> COMMENTS: y KrV �Ql <br /> ACCEPTED BY: S VL(` r EMPLOYEE#: C1 1 DATE; -��i__�• <br /> ASSIGNED TO: td EMPLOYL%#: DATE: lk <br /> Date Service Completed (if already completed): SEavICE GORE: 4 G?& PIE! t~r <br /> Oeo Amount: Amount Pald j Payment pate t <br /> Payment Type 6s invoice# Gheck# J Rscel4ed 13y: <br /> tt I <br /> bLU'EY2; tie "��R- vu o <br /> EHD 48-02.028 s t� SR FORM(Golden Rod) <br /> 07/17/08 <br /> i <br />