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1 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> OWNER/OPERATOR � - - <br /> ,�" Vcmllmclif <br /> BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �V`') c��w�/ ��� ` ?5,7q <br /> t <br /> _ / Street Number Direction r Stre�Na~me l Zi ,7 <br /> hJME or MAILING ADDRESS (If Different from Si Addre <br /> t� Street Number Street Name <br /> CITY C STATE ZIP f, <br /> © C I (f <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 3 �( <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME - `` PHONE# I l ExT. <br /> +-1l ",� <br /> HOME Or MAILING ADDRESS I r FAX <br /> CITY / STATE ZIP Cy!S�(�,• <br /> Od <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> APPLICANT'S SIGNATURE: DATE: Z _ <br /> PROPERTY/BUSINESS OWNER 11PERA71 / ER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tire <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 to me Or <br /> my representative. P"WEE 921141"01" <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> JUL 2 3 2195 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPL OYEE#: DATE: <br /> ASSIGNED TO: r'l EMPLOYEE#: DATE: �O <br /> Date Service Completed (if alre dy completed): SERVICE CODE: P/E: <br /> Fee Amount: - O Amount Paid Payment Date 7 v� <br /> Payment Type invoice# Check# Received By: <br /> i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />