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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu Mess or Property FACILITY ID # SERVICE REQUEST # <br /> 4,3 § /��4 c.) q �7 311 ) <br /> OWNER / OPERATOR � '` k 4bG CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME ` 1 <br /> SITE ADDRESS <br /> It U <br /> Street Number Direction Street Name Cit ZI od <br /> HOME or MAILING ADDRESS (ifDifferent from Site Ad ress) <br /> 4j/ <br /> l ` t 6u rnx, Street Number Street Name <br /> CITYf STAT ZIP <br /> ch J L 6 <br /> PHONE #t ExT• APN # LAND USE APPLICATION # <br /> ( ) - 2 ( � — o3 (a � <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEV�56 , � v y� PHONE # y 6 J. 1 <br /> HOME Or MAILING ADDRESS FAX # L <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 accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FED L la <br /> APPLICANT' S SIGNATURE : DATE :: <br /> PROPERTY / BUSINESS OWNER ❑ OP TOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to si n Is required Tif <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 /> 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 : .� f'� t -- Ys*? O tess� p <br /> COMMENTS ; �� + / � J _ ,` �, / „ E^� 1�' ' • <br /> �f Fe 1 c <br /> S'4 s <br /> yE NV 4o <br /> ACCEPTED BY: _ EMPLOYEE #: DATE: 2 `tgRT r �NTY <br /> ASSIGNED TO : P /� O EMPLOYEE #: DATE: 121 <br /> Date Service Completed ( if already completed) : SERVICE CODE: L9J PI E: 7J <br /> Fee Amount: 2 Amount Pa Payment Date <br /> Payment Type V 1c, <br /> Invoice # Check # i 7 � �� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />