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SAN JOAbtUn. COUNTY ENVIRONMENTAL HEALTH L...r)ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property l y� FACILITY ID# SERVICE REQUEST <br /> # <br /> MCIAZ CT ur-e j JTOrn � a✓�L �-r1-� 7 � C� 0 �j �— ob--? C1 0 D <br /> OWNER/OPERATOR a�� CHECK If BILLING ADDRESS <br /> --T�-I' C'Ici <br /> FACILITY NAME <br /> SITE ADDRESS M Q}��/^�y� J� V CAI M Gn I �C ct CJ .3.3to <br /> 15 Street Number Direction r " t 1 ' treet Name 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 /> aOq) 63 yUL-iU <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> ( ) C `�7 C� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE g TO p <br /> Q m 0Z <br /> / 00 G A `,� _/� �, CHECK if BILLING ADDRESS <br /> BU r ESS AME //` Q/ PHON ) I�t, _n'3 x <br /> I` Poo/ VY 7 <br /> HOME or M ILING ADDRE S FAX# <br /> CITY S O / a� STATE C 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 and FEDeRAL w <br /> APPLICANT'S SIGNATURE:``/ ✓1r/ DATE: �y <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 <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 assessme rmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it IS pro 1 � r <br /> my representative. •►� lvT <br /> TYPE OF SERVICE REQUESTED: ^ L-lam) I" <br /> COMMENTS: �JOgQ(J O ?O� <br /> M �GqO W <br /> �9CTy0�.q�N�41 <br /> FHT <br /> ACCEPTED BY: 1 ` EMPLOYEE#: DATE: s <br /> ASSIGNED TO: Q-)C \ ( EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE CODE: G�—��` PI E: J' <br /> Fee Amount: �C) Gt� Amount Pai Payment Date <br /> Payment Type Invoice# Check# 7 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />