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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> GQ .� S -� a-h tom.. f 1� u � o it 00 S12:4 � <br /> OWNER / OPERATOR <br /> CHECK if BILLINGADDRES <br /> FACILITY NAME , V/� <br /> SITE ADDRESS 2. $ "� S S rA I I 7S C"i fi s �rez" <br /> Street Number Direction Street Name city do <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE #') EXT. APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> v � v t SaAo. 0 � eZ CHECK If BILLING ADDREM <br /> BUSINESS NAME PHONE # EXT' <br /> I) I a � 0%.A & r) o /ems /U . S� � .Or CL �► c ( 12JI �o - 080 <br /> HOME Or MAILING ADDRESS FAX # <br /> 3O ) cj C ( ) <br /> CITY c STATE L' ZIP y 50 <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 /> 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 SIGNATOR DATE : IO - Y- / <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f 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 /> 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 . 'Yy� <br /> TYPE OF SERVICE REQUESTED: f � {� r vti T, <br /> COMMENTS: ! cV `f- cu -d- read y Via TZ <br /> sus a� d � � �� f � nd� A 1-1 <br /> � f l trti � � Sr/O � - ! 5� � I / .1� cl � �� I v► , av' c�v -fU C �-� �y lav T� � t�-e <br /> u,. z . s V^Qa, ,�,'� �.Py>ti ; <br /> Ct Co� C re. ! 1140< S�IYr iV cov*er fu � � / l $ ✓ w <br /> ACCEPTED BY: 1 p /, ` EMPLOYEE #: DATE : <br /> ASSIGNED TO: fJ L� EMPLOYEE #: ( DATE : 10 <br /> ►y <br /> Date Service Completed (if already cont leted): SERVICE CODE: PIE: <br /> /� el <br /> Fee Amount: ✓� 2cw Amount Pai Payment Date /d <br /> Payment Type invoice # Check # �E Recei d By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />