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SAN JOAQL OUNTY ENVIRONMENTAL HEALTH _PARTMENT <br /> i SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Isco � lOb �IRa o 81 13 <br /> OWNER/OPERATOR / -�, <br /> �I < CHECK If BILLING ADDRESS <br /> FACILITY NAME �j✓ <br /> SITE ADDRESST <br /> SSG Street Name F;Zi�o�2 <br /> de <br /> HOME or MAILING AD RESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 0 5D OZ <br /> PHONE i#Z Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR (4 <br /> REQUESTOR ///�— <br /> /o re `f /�- CHECK If BILLING ADDRESS <br /> vv / 'ter/ <br /> BUSINESS NAME PHONE# EXT. <br /> C (---7C' 6/ 7 - Oft ! <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE /' ZIP C(S sq l} <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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUREv�/ \ DATE: ;2 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT mon Ti^Gc 1: <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 environm nt I ite s e Information <br /> rte , <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at th t e I d6 rtV �d*t m8 Or <br /> my representative. r_ <br /> TYPE OF SERVICE REQUESTED: !•\ ,Qi� PIq <br /> COMMENTS: <br /> EN MENTAL HE H <br /> S AN A� ,0 4 RMITIb,-RViCi <br /> HE,qIV ROOA QA(M C UNn' <br /> D T =4ZC ACCEPTED BY: EMPLOYEE#: ME DATE: <br /> ASSIGNED TO: EMPLOYEE#: � L eD DATE: Z 12-6 <br /> Date Service Completed (if already completed): SERVICE CODE: G-21 P/E: If2o <br /> Fee Amount: 0 Amount Paid Payment Date -Z-/ Z ZD z0 <br /> Payment Type Invoice# Check# C C 0 Received By:105 Wl( <br /> / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />