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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST <br /> N ', can kuluvwt 60g17� 7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME a� l s <br /> SITE ADDRESS 3X60,/'r ] i 953 <br /> Street Number Direction '\J I l Street Name 'j�-�j i Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) g 2 n/ M� Wd a <br /> Street Nvumber V 1 �-Street Name <br /> CITYZ P <br /> fi Cc1 S T <br /> aq'5336 <br /> 53 3 6 <br /> PHONE#1 N EXT. APN# LAND USE APPLICATION# <br /> cam) `'f got 3 7 q/ <br /> PHONE it2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` r <br /> CHECK'tf BILLING ADDRESS <br /> BUSINESS NAME�n�t(\ r. PHONE# EXT. <br /> 11 1 l t (l` <br /> HOME or MAILING ADDRESd FAX# <br /> 11-J3 uU a1ayfve-(�) c�A- c ) <br /> CITY STATE VfOMICCAC.� ZIP CI <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 application and/That he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST TEIJ FEARA aws. <br /> APPLICANT'S SIGNATURE: DATE: ` �I I <br /> PROPERTY/BUSINESS OWNER `, OP R TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1:1If APPLICANT Is not tie LING 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 time it is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: -fW ov-6owir PA VA. <br /> COMMENTS: 18cz'�� r <br /> Nov <br /> 3 p 21018 <br /> N� <br /> tif TViRONCOIN <br /> ACCEPTED BY: EMPLOYEE#: Cqrn r?( DATE: <br /> ASSIGNED TO: �I i� ✓1 I/ EMPLOYEE#: q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Ul1i I PI E: <br /> Fee Amount: .15 Amount Pai � Payment Date I DI/ <br /> Payment Type `� Invoice# SWC # Received By: <br /> EHD 48-02-025 If �- + j, SR FORM(Golden Rod) <br /> 07/17/08 i V ( � 1� 'i�v �Ct -ti,�,✓� <br />