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ENVIRONMENTAL HEALTH tJCPARTMENT <br /> SAN .IOAQI,f.J COUNTY <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> `7 2.6c�7-1�13Z- <br /> OWNER/OPERATOR �w �1 <br /> v` CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �})9C, M'N-A Cr, <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAIILADDRESS� <br /> MAILING �(I Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT� rATqN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS E] <br /> I # <br /> BUSINESS NAME PHONE EXT.� <br /> i <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 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE sand RAL la <br /> XPIPPLICANT`S SIGNATURE,;-' ' DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> i <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 pwner 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ` , C lV T <br /> � Fr <br /> ��E1VED <br /> ?01 <br /> �o° �� <br /> ACCEPTED BY: '-l kr6l6k EMPLOYEE#: DATE: 7-11 -(7 <br /> ASSIGNED TO: f '� EMPLOYEE#: DATE: '7 -(7-17"-'(7-1 7 <br /> ` t l <br /> Date Service Completed (if already completed): SERVICE CODE: LI C, l P I E: H L4 U <br /> Fee Amount:Jt 51,J,-) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />