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SAN JOAQd*COUNTY ENVIRONMENTAL HEALTH 90CPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> N CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> L, <br /> SITE ADDRESS (��� �` �D G! "(Q �� J U�,&' �4j 20 <br /> Street Number Direction Street Name _" Zi Code <br /> HOME Or MAILI G ADDRESS (If Different from Site Address) ?[/ (s' <br /> C7 1I Z -�3-' <br /> S/� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 /EXT. BOS DISTRICT LOCATION CODE <br /> SERVICE REQUESTOR <br /> REQUESTOR ��� /J <br /> g <br /> G,rq mss, k�Y/(� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS /q360 /�/ o /,( J FAX# <br /> CITY l Le M 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 /> 1 also certify that I have prepared this application and that t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL wS. (� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT is not the BILLING PARTY./hoof 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 te_ fprl�ed to me or <br /> my representative. c�{l�;�6�'`�� <br /> TYPE OF SERVICE REQUESTED: �G 'I <br /> COMMENTS: J C' AUG' . I <br /> v( Nrr <br /> SAN 4\ <br /> JOA 7 <br /> HEA H DEPARTMEN <br /> ACCEPTED BY: J V�� EMPLOYEE#: _. DATE: <br /> ASSIGNED TO: ✓� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: X31/ <br /> Fee Amount: -4 })o_C50 Amount Paid Payment Date <br /> Payment Type Invoice# Check# /{ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />