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SAN JOAQULd COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 44"(- bo s F--66 / &l9& 5R 66`77 lq �7 <br /> OWNER/OPERATORG <br /> no <br /> L S /• CHECK If BILLING ADDRESS <br /> n <br /> FACILITY NA Cir t k <br /> SITE ADD S; 6 n� r�— / ,• r•A I^2Q <br /> L Str¢et Number (D/IrVedI. Street Name 4 - CRYL%Z,T\'C¢tle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 23 r <br /> Street Number Sir et NamL) <br /> CITY STATE zip Q�^ <br /> PHONE#t �1 VV APN# LAND USE APPLICATION# ...JJ <br /> ( O <br /> PHO #2 EXT. BOS DISTRICT LOCATON CODE <br /> f ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR sr0 " CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME 4 PHONE# EaT. <br /> HOME or MAILING ADDRESS FAX# <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 a ERAL hV. <br /> APPLICANT'S SIGNATURE: <br /> � DATE: <br /> PROPERTY/BUSINESS OWNtik PERAT (MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not fh G 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' formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provi*aq a(y <br /> my representative. Air <br /> TYPE OF SERVICE REQUESTED: q <br /> COMMENTS: S r t� <br /> AIV UOA / <br /> HEALTH 0 PARAt <br /> lY <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: pw lv7a DATE: <br /> Date Service Compl (ifa dy completed): SERVICE CODE: Q P D3 <br /> Fee Amount: Amount PaidCDU Payment Date 'f122,117 <br /> Payment Type Invoice# Check# Rece/ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />