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SAN JOAt EN COUNTY ENVIRONMENTAL HEA,,_d DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# Iirst <br /> ERVICE REQUEST# <br /> x S5� <br /> OvV E /OPERATOR <br /> y �` CHECK((BILLING A000.ESS El <br /> CAVI)A <br /> AGILITY NAME / a JC �Y��l ct s II 1 <br /> SITE ADDRESS ;'�p �(� S Se&ra v&4,4, k O S�' LUGC ( 12�J <br /> Street Number Direction Street Name - CRY Zip C.de <br /> HOME Or MAILING ADD ESS (If Different from ite Address) _ <br /> . Street Number Street Name <br /> CITY ' (d k STATE(AZIP ulO <br /> t <br /> PH-O-�N�E�G#1 Ems. APN# 4 <br /> LAND USE APPLICATION# <br /> PHONE#2 ExT BOS DISTRICT LOcAnoN.S�DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECKif BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <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 <br /> or 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 IOAQUN <br /> COUNTY Ordinance Codes,Stan rds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNAT DAT <br /> i <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGE ❑ <br /> 1rAPPLICANT is not the BTLLTNG PARTP 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN 70AQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tk�a¢Ie time it is <br /> provided to me or my representative. �icer <br /> TYPE OF SERVICE REQUESTED: - OT'e 0- <br /> COMMENTS: �' SAN4 <br /> hFq�tioogpT� ry <br /> ACCEPTED BY: t ,�ar�( ' EMPLOYEE#: DATE: b r 1 I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l7 6 PIE: <br /> l <br /> Fee Amount: t 15- ;Z) I Amount Pai /aS�-OD Payment Date 67"3 <br /> Payment Type Invoice# Check# Receiv d 6y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />