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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GyZ v0 3D03D <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 22S v C `�L/ <br /> Street Number Direction �./Y I Street Name Cit ZipCode <br /> HOME or MAILING DDRESS (If Different from Site Address) <br /> Gd Street Number Street Name <br /> CITY STATE <br /> c ` A r,4S� U <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> G` ) 2 T <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> r EXT. <br /> C2 <br /> BUSINESS NAME /� � r ,/t� _ ,...r.I � PHONE# <br /> HOME Or MAILING ADDRESS � I � FAX# � <br /> CITY co ( l� STATE CA <br /> ZIP OfC Z–(_f v <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 /> I also certify that I have prepared this pplicati U-that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE• 14 DATE: t <br /> PROPERTY/BUSINESS OWNER OP R TOR//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 i Aofrmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is providod or <br /> my representative. Aft <br /> R I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 3 <br /> -�LTh,QFp�T q4H <br /> MFHT <br /> ACCEPTED BY: \ Moa o EMPLOYEE#: DATE: l �1 <br /> ASSIGNED TO: EMPLOYEE#: ^' DATE: ' --51 <br /> SERVICE <br /> it <br /> Date Service Completed (if already completed)'. SERVICE CODE: F I ri P 1`E: I 00-2 O <br /> Fee Amount: * 1 -z Amount Paid /S�,Ub Payment Date 12 <br /> 7"31117 <br /> Payment Type Tinvoice# Check# �� c70 Received By: <br /> 7/r— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 1 <br />