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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Pf Business or Property FACILITY ID# SERVICE REQU ST# <br /> O NEfRFf�/OP TOR <br /> CHECK if BILLING ADDRESS P/ <br /> FACILITY NAME Wog/� <br /> SITE ADDRF/�,1// //d//7 Z�� <br /> *Y] <br /> 7 ((�� Street Numbe Direction Street Name <br /> HO E r A l ADDRESS (If ifferent fT7rh-m Site Address) <br /> l ��Sq��( Vr L Street Number Street Name <br /> CITY r0 � STATE ZIP `��n <br /> PHONE#1 / EXT, APN# LAND USE APPLICATION# J C/ <br /> g21Z <br /> PH�O'NE#2 /, / EXT. BIDS DISTRICT LOCATION CODE <br /> (7r°) (/S%/y �/J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> ' BUSINESS NAME PH NEO# _ / EXT. <br /> HOME or MAILING ADDRESS L (/ FAX# CY <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 accord nce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard S E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titre <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 in, ion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is providi <br /> my representative. -'e �I• <br /> TYPE OF SERVICE REQUESTED: 04 (Q GheC K <br /> COMMENTS: <br /> Q41V <br /> ti F,y�°' CO <br /> �Q�� � 9 <br /> ��HOFpq�Nq4 1Y <br /> ME <br /> ACCEPTED BY: Ln V n2 EMPLOYEE#: DATE: I 3 D <br /> ASSIGNED TO: Nde EMPLOYEE#: DATE: 17,W <br /> i 6 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P/E:II D/ <br /> Fee Amount:tt <br /> S a Amount Paid L� lo.D� Payment DateSK <br /> 3� <br /> Payment Type Invoice# Check# Recei ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />