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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ` <br /> DYI r{ CHECK If BILLING ADDRESS <br /> FACILITY NAME �u l <br /> fl <br /> SITE ADDRESSEEj � ��� Qo v N r� <br /> tr et Number Die tion (�, treet Name cityi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I� 1 Street Number Street Name <br /> C4Y ST/�TE ZIP C� <br /> S_d �o r � <br /> pH<i/�"#11F - E�.j• APN# LAND USE APPLICATION# <br /> 4 P PHONE#i? EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ©`n �v v� L< <br /> Y l (-A CHECK If BILLING ADDRESS <br /> BUSINESS NAMEul Z' PHONE# C EXT. <br /> HOME or MAILING ADDRESS `yl 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 /> 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: �R 0 K q 7dk1 L( L� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /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 environmental/site asent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the oMovided to me or <br /> my representative. t� <br /> TYPE OF SERVICE REQUESTED: f&o,� �,Gmyu��h� 016 <br /> COMMENTS: JOAQu1N Gout-A"SA AL <br /> ENVtROMEN-V E <br /> HEA►-TN HEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: 4r4 1(p <br /> ASSIGNED TO: ��( �1 D EMPLOYEE#: DATE: ll/ II(µ I wIn <br /> Date Set-vice Completed (if already completed): SERVICE CODE: P I Lt: I�D� <br /> Fee Amount: (��-(� Amount Paid 3 U Payment Date Uri <br /> Payment Type .S Invoice# OR, 3 ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />