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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ffEww OD-D yl/j FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Y CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> S-- 3p� ��� : �� A-vP�Q �{ /06 5 Tvc�%•�� �S�o7 <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) .� Le Y (f Ye ,� L/—'I YG <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# J� LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR , <br /> REQUESTOtR� CHECK if BILLING ADDRESS1.�1 <br /> (Q t <br /> BUSINESS NAME /] PHONE# p EXT._S t<i e <br /> HOME or MAILING ADDRESS 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 a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and F DERAL la s. <br /> APPLICANT'S SIGNATURE: c DATE: 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same tlrT A-,`I pr�yWed to me or <br /> my representative. izt47' <br /> TYPE OF SERVICE REQUESTED: C; ( () <br /> COMMENTS: L4`� ^ 1? <br /> �S v SAN `!1 <br /> X0 <br /> ENVIRONJOAQUIN COUNTY <br /> HEALTH DEp lR AL <br /> NT <br /> ACCEPTED BY: �� ��J EMPLOYEE#: DATE: —3 -/ <br /> ASSIGNED TO: I` L EMPLOYEE#: DATE: -:13 -/7 <br /> Date Service Completed (if already completed): SERVICE CODE: /n I P/E: 1 &,)2 <br /> Fee Amount: r' .) ���' Amount Paid Pay ent Date <br /> Payment Type jInvoice# Check# Received B, Y' � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />