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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r. <br /> OWNER I OPERATOR C <br /> ,p /�� CHECK if BILLING ADDRESS <br /> FACILITY NAME r 3 IJ F�-tkv1C P��S C `��L S I+ t/r`��0 J� <br /> j SITE ADDRESS r nt/V �/ 1— ST • Y` 1 z / <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �U �y s k 0 e W C ,k-1 <br /> /� Street Number Street Name 1 <br /> CITY �-00( sm Zip S Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> cl <br /> PHONE$2 _7 EXT. BOS DISTRICT LOCATION CODE <br /> f/y(ofit} / �L o <br /> L CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR j ,� L �' �� N <br /> �(� CHECK if BILLING A6DRES5E] <br /> i BUSINESS NAMEv PHONE# EXT. <br /> HOME Or MAILING ADDRESS 1. L� FAX# <br /> Oro -t v t�C U Q t� ( ) <br /> CITY LV Pi STATE CA— ZIP q5Z �Z <br /> BILLING ACKNOWLEDGEMENT: 1, 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 applicationand that the w o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TE and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER© OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided to me Or <br /> my representative. Ph <br /> V � <br /> TYPE OF SERVICE REQUESTED: f of �Uf or a F+1 <br /> COMMENTS: EO <br /> IC f`,2 8 .�ors <br /> 5A1V JOgQUiN C <br /> HE ENVi MEN DUN <br /> ALTff ID,�,,,,T t . <br /> ACCEPTED BY: L�rti /J 1 o EMPLOYEE#: DATE: <br /> p ` r-I rr__ff!! fiv <br /> ASSIGNED TO: ( �T G Z EMPLOYEE#: DATE: E �U <br /> Date Service Completed (if already completed): l i SERVICE CODE: C f PF l E: <br /> Fee Amount: Amount Paid" �t�� Payment Date <br /> Payment Type Invoice At Check# Received By: _ <br /> EHb 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> new <br /> S <br />