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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SE VICE REQUEST # <br /> OWNER / OPERATOR ((( <br /> r, Q 4 ` 7 p _ u6 tA`xm n _ <br /> FACILITYME IG CHECK If BILLING ADDRESS <br /> `mac �l (� <br /> a � Lass <br /> SITE ADDRESS 'Sh,"G�1 <br /> Street Number Direction � (� 41P - reef Name Cit Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> h 1 �r 'y�� � ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME +\ V c �^ [� PHONE ExT' <br /> HOME or MAILING ADLPRE S FAX # <br /> CITY C` � � STATE 01 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 projector <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . q <br /> APPLICANT' S SIGNATURE : ` LSU- %-l: �-G{a �j •� � DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT L C'v 1 � ({�! (l( C <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 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 p,Lovided to me or <br /> my representative . RIO <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : MAIR 0 7Sq� #44 O� FO <br /> �T <br /> l , aiZ0NiiNIr, N%,%N�,QgQUj 0?? <br /> qRT ?A/ COO <br /> Y <br /> PIA <br /> ACCEPTED BY : EMPLOYEE # : DATE : $ 1 Z <br /> ASSIGNED TO ' � � tj <br /> �� � / v, err EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : , eff �/✓� � PI E : 2zd <br /> Fee Amount : Amount PaiOO Payment Date <br /> Payment Type Invoice # Check # �2� 31 Received By : <br /> EHD 48-02 -025 SR FORM (Golden Rod) <br /> 07/17/08 <br />