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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> cis � � (A FAD 0014RO S� 0Ug�S �� <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> �� <br /> SITE ADDRESS e� � aIV46 S <br /> Street Number Direction 1 Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) BA <br /> Number Street Name I <br /> CITY STATE ZIP CE/ V <br /> i Move <br /> � 4000 <br /> PHONE #1 Ex-r. APN # LAND USE APPLICATION # C <br /> ( ) SAN 2 ZO <br /> CO <br /> PHONE #2 ExT. BOS DISTRICT <br /> COU <br /> DEP &NTA TY <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR Nr <br /> REQUESTOR Q ' CHECK if BILLING ADDRESS <br /> BUSINESS NAME E <br /> P # <br /> & bfo �S U C . cao �� <br /> � <br /> HOME or MAILING ADDR SS tFAX # <br /> kv tr ' r ` ( ) <br /> CITY C+ � t l - r STATE ilk <br /> 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 and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : � Qe t t,Ol� V ' `� � �' DATE : / '�� ►� ��0p4 rl <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT LVl.tl.�) il [74.tL� b4t eV <br /> /f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required VTitle <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 provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : ST / � l / {� �/ I Q <br /> COMMENTS : <br /> I <br /> l <br /> ACCEPTED BY : / EMPLOYEE # : DATE : <br /> ASSIGNED TO : � G O �d EMPLOYEE # : DATE : 2Z <br /> Date Service Completed (i ( ready comple ed) : SERVICE CODE: � P 1 E: 230 <br /> Fee Amount : / DO Amount Paidi�� 01"') Payment Date 7 ZZ <br /> Payment Type Invoice # Check # 73u Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />