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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />% <br />CJ C_ J LJ I� <br />FAX # <br />` � C 1-1 ` <br />OWNER / OPERATOR <br />,n/" nl',�j� �/ CHECK If BILLING ADDRESS El <br />' l / /c / J` hl / G� 1� ,✓ ' <br />—J <br />FACILITY NAME <br />GA>?�s <br />SITE ADDRESS <br />/GS <br />1 <br />p� <br />/ ` <br />/Street <br />JG, K7-(>j <br />�� <br />C� ��I OI <br />l <br />Street Number <br />D eotJion <br />">' <br />Name <br />Ci <br />Zi Code <br />ME Or MAILING ADDRESS (If Different from Site Address) <br />DATE: <br />4ftName <br />ASSIGNED TO: <br />Street Number <br />DATE: <br />CITY,^� <br />SATE ZI0_ <br />A <br />PHONE #1 EXT. <br />(ZJ9) Z�0 `� <br />APN # <br />% <br />- 03�-- D4 <br />LAND USE APPLICATION # <br />/q /<GC7 ZZ <br />PHONE #2 EXT. <br />( ) <br />,Qz) <br />BOS DISTRI//CS�T <br />©tel <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />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-tM9 the work to rform will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST gTE and FEDE laws/ <br />APPLICANT'S SIGNATURE: L fait/ C. DATE: 7 <br />PROPERTY I BUSINESS OWNER!'SI OPERATOR / MANAGER ❑(—OTHER AUTHORIZED AGENT ❑ �/Z 2,5��� <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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time it is provide, e Or <br />my representative. �1_zo TYPE OF SERVICE REQUESTED: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />IJ <br />COMMENTS. <br />i�VRo�,y <br />Z <br />`TyOEpgRT <br />�� <br />MFS <br />3 0 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Co pleted (if already completed): <br />SERVICE CODE: <br />P 1 <br />Fee Amount: g <br />Amount P ' <br />,Qz) <br />Payment Date <br />G� <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />IJ <br />