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/9000 ? <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> the vyb �1 [ p ��ut- CHECK If BILLING ADDRESS <br /> �'YU <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 1103 n S� m�Y? rr CSG 7T7ZIp <br /> Street Number Direction Street Name Cit ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name E ,. <br /> CITY STATE ZIPit - <br /> / t <br /> PHONE #1 EXT, APN # LAND USE APPLICATION <br /> ( ) <br /> PHONE #2 EXT. BOS DISTRICT 88 T,19N CODE <br /> CONTRACTOR / SERVICE REQUESTOR � O�/�gRIV <br /> t4,4 <br /> REQUESTOR T <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # �y ExT. <br /> ( <br /> HOME or MAILING ADDRESS FAX # <br /> CITY STATE 014 ZIP <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 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 : DATE : f-a2�i - 2ntq <br /> PROPERTY / BUSINESS OWNER ❑ / MANAGER ElOTHER AUTHORIZED AGENTIf APPLICANT iS not eRATOR <br /> ING PARTY. proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAS 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 to me Or <br /> my representative. _ <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> ENVIRONMENTAL HEATH <br /> ACCEPTED BY: ��� EMPLOYEE # : CL J S ' 19 <br /> ASSIGNED TO : \Nk � EMPLOYEE M C1 DATE: Z � � ' <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount: Amount Pal Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />