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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 0,,� FACILITY ID# SERVICE REQUEST## <br /> OWNER/OPERATOR _ <br /> CHECK If BILLING ADDRESSf� <br /> FACILITY NAME 0,40 ��� ,t�OCr1/`0 <br /> SITE ADDRESS 1 3 ��Z� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAKING ADDRESS (If Different from Site Address) <br /> �J0 3 23 Street Number Street Name <br /> CITY STATE ZIP C 5�2�11-/C/�' ej <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# / <br /> (2-0j) /,;� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `--� � � � �- / PHONE# EXT. <br /> •r�/ <br /> HOME or MAILING ADDRESS ✓ FAX# <br /> CITY /- O0 / 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 and FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE:x— DATE: -7-5110/ <br /> / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑! /slZ��2 ��6� <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 t0 me or <br /> my representative. a to— �/I�fq <br /> TYPE OF SERVICE REQUESTED: U�- QAll A <br /> � �� <br /> COMMENTS: <br /> rt tLVi I�5 SAN Jo 2016 <br /> HEA��H R A�NTq`N <br /> RTjb1EN <br /> ACCEPTED BY: EMPLOYEE#: DATE: i3 ./C•./ <br /> ASSIGNED TO: EMPLOYEE#: DATE: J _/D_/ <br /> Date Service Completed (if already completed): SERVICE CODE: �, ` P/E: <br /> Fee Amount: — Amount Pa g'b, 6 Payment Date I� <br /> Payment Type Invoice# Check# 3�0 '- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />