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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property L� FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR LL , ee (n�__A04,, �\J <br /> I.' L Lo V S S a 1—r cit E N CHECK If BILLING ADDRESS \ <br /> FACILITY NAME <br /> /SITE ADDRESS z y-"3 <br /> r0 Street Number Direction �L��L—StrAeCNaMe ' ~� CI ZIp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> J N-/F5rT 1—� Street Number 'rr Z1J2 Street Name <br /> CITY \ W TATE —1, IP <br /> A S y <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (5)'0) 1 23 r 202'J U(p 2_GtC C>L-( <br /> PHONE42 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) (J� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the <br /> undersigned g 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 I ws. ` Q <br /> APPLICANT'S SIGNATURE: --� DATE: �J ^-1 A <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ElTH?�,AUTHORIZED AGENT ❑ <br /> ff APPLICANT is not the BILLING PARTY Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assess rpr}(jnf�ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same lime It IS �rooddhhll��BB �q <br /> my representative. 1v- <br /> TYPE OF SERVICE REQUESTED: t)e Fit L1 utr' <br /> COMMENTS: ?018 <br /> �JOAoul Q <br /> NilW°f PAR ZAL <br /> eAlr <br /> ACCEPTED BY: -A EMPLOYEEM DATE: <br /> AsSIGNEDTO: FAHI " EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �,�, I P/E: <br /> Fee Amount: Z �' Amount Pal /S� D� Payment Date 3� <br /> Payment Type Invoice# Check# /a/� ecei edBy:: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />