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t <br /> SAN JOAQUR COUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 14 SL 6Flo <br /> OWNER/OPERATOR ( CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS1 !t, elD't/t <br /> n/0' Street Number Direction Street Name city ZID 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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR + �r e <br /> 11JI> I CHECK if BILLING ADDRESS <br /> BUSINESS NAME / `e PHONE EXT. <br /> )L <br /> C 2a 36le <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 /> 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 /> APPLICANT'S SIGNATURE: DATE: �11L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: kAlo -Z — (" <br /> COMMENTS: • <br /> SAM j 3 Z 7 <br /> H FNV/RQ l/IN COU <br /> �fQH NMFN Tl' <br /> ACCEPTED BY: EMPLOYEE#: W DATE: `� / TMS T <br /> ASSIGNED TO: 0e 1kb EMPLOYEE#: `�J DATE: to <br /> /� t <br /> Date Service Completed (if already completed): SERVICE CODE: ZI P I E:l.1 l b <br /> Fee Amount: 2d� Amount Pai 3 ��U Payment Date <br /> Payment Type / Invoice# Check# --211741 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />