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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T e of Bus' ess or Property FACILIT ID# SERVICE REQUEST# <br /> �— [\� � s ,-CY,- 7gSI � <br /> OWNE PERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> UiJ <br /> u(� <br /> SIT Street Number Direction " 1 4 treet Name kJ 0 Zi Code <br /> 0 <br /> 6Eor M NG )DRESS I(_f Diff renMTite Address) <br /> �� j`/l� � Street Number Street Name <br /> CITY / STOf ZIP / ��T f <br /> qb„.� _ 4 l _.1 EXT. qpN# qO_ /O� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT- I V <br /> OCATION CODE <br /> ( ) c, ( e <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES of 5 <br /> I .�] CHECK If BILLING AD-, SO <br /> BRt USINESS NAME NAME � { ,� 64" ) PIV) 70--OZ <br /> 0 --O EXT. <br /> HOME or MA,IQII� SS j C �� Wt- <br /> CITY <br /> fax#L6lc777U L I l STATE l ZIP 3 6 <br /> BILLING ACKN WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project peciflc ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my busin s as identifi ' on t ' orm. <br /> I also certify that I have prepared thi a plication n that e'work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards S ATE and ED AL la <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY I BUSINESS OWNER -OP ATOR/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 loS41ed at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/siteent information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 2S SOOn as It IS available and 2t the S2111 `I��ded to me or <br /> my representative. PP ����ij��+ <br /> TYPE OF SERVICE REQUESTED: Cy l "c(C— �► 1 <br /> COMMENTS: Pv� GpV <br /> -hA` Np�pM <br /> ACCEPTED BY: EMPLOYEE#: DATE: /'"7_ <br /> ASSIGNED TO: ` EMPLOYEE#: DATE: U _ ( // _/ <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid *L4 S' Payment Date 8 8 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />