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SAN JOA(., _.J COUNTY ENVIRONMENTAL HEALTH _2PARTMENT <br /> SERVICE REQUEST <br /> Typ�jof Business or Property FACI ITY ID# SERVICE REQUEST# <br /> I-, _--,o <br /> W, <br /> OWNER/OPERATOR <br /> A--L� I •�� CHECK If BILLING ADDRESS <br /> t_ <br /> FACILITY 4qE <br /> S TE ADDRESS <br /> Sl�ber C 4Le ���O 7 <br /> Street NumDirection [reef CI 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� 1 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME f'`l PHO1NE Exr. <br /> HOME or MAILING ADDRESS. 1 FAX# <br /> CITY .�� C- � � STATE / ZIP Ll <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 7med will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL law <br /> APPLICANT'S SIGNATURE:/ DATE / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign IS require/ 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. P <br /> TYPE OF SERVICE REQUESTED: yl'CA �� ^ - C_ L s <br /> ivZO <br /> COMMENTS: <br /> JUL 1 7 241 <br /> Sq EN�AuoUl�t COU <br /> HEALTH )CPA R ,_ T y <br /> T <br /> ACCEPTED BY: 1 no <br /> ` EMPLOYEE#: DATE: <br /> 7 <br /> ASSIGNED TO: I I� j - .�.� ` EMPLOYEE#: DATE: /) _17 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: C <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# 2c� j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />