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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =S�E'RVICE REQUEST# <br /> 400 rho e�au� �le� oo"1��-°l� <br /> OWNS /OPE OR <br /> f;L CHECK If BILLING ADDRESSff <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ber Direction tre a - <br /> HOME Or MAILING ADDRE (If Different from Site Address) r '� Ver 'A,, C.Ida <br /> t Street Number beet Name <br /> CITYL'c i+ SGAE ZIP q SZ YD <br /> PHONE#1 G( EXT, APN# LAND USEAPPUcATION# <br /> (Zol) (o371(E%)g01 .iL— <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR q/ If I <br /> C rl L {-III CHECK If BILLING ADDRESS <br /> BUSINESS NAME / Em <br /> L� O S PHONE# <br /> HOME or MAILING ADDR I n FA%# <br /> e C.0--le ( ) <br /> CIN I JoJ /�/ 'Ale STATE CA - gs2ya <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 rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, StandardrSTand FEDERAL IAPPLICANT'SSIGNATURE:: DATE: <br /> r� <br /> C <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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 abog <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment i @ A <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time Il Is �{Va,Gn`�" <br /> my representative. E` <br /> TYPE OF SERVICE REQUESTED: '� I ec 3y-) <br /> 1 \5 <br /> COMMENTS: DVN, <br /> LIG � �G 702�� SPNSO POM H �Nt <br /> NEA H�gP <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: IVI SS) EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: () PIE: .3 <br /> Fee Amount: Amount Paid 'Tp 1-3D- 01D Payment Date <br /> Payment Type V : Invoice# Check# Received By: <br /> coNr <br /> - z$ � 3gg ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />