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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �D K17L . CHECK If BILLING ADDRESS <br /> FACIUTYNAME <br /> ZISITE ADDRESS r/' / �1�/�'/ I / <br /> 7, Street Number Direction 4E ; gtreet rya ��ry 9J�/c, <br /> HOME or MAILING ADDRESS (If Different from Site Address) cityZI case <br /> rT C" <br /> CITY �y—� ,/ � /Street Number Street Nam¢ (�]�/' /�] <br /> 0 �—�N $T� ZIP %J c(I <br /> v <br /> PHONE#1 EXT.. qpN# <br /> 2 --r2—r2 Q 2 1 Li LAND USE APPLICATION# <br /> PHONE#2 <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ( CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> Oe <br /> HOME HOME Or MAILING ADDR,ESAS� /'y -LP ? LIZE <br /> FAX# <br /> CITY .� Ai rD / $TATER � ZIP q <br /> BILLING ACKNOWLEDGEMENT/:YI, the undersigned property or business owner,yoperator or authorized agent of same, <br /> acknowledge that all Slte and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SraTEand L laws. <br /> APPLICANT'S SIGNATURE: DATE: 9)(,'- z) 9$ <br /> PROPERTY/BUSINESS OWNER[3 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon aS It Is available and at the Same time It Is providee Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 01/V!,TL .i1i� 69 6! <br /> O <br /> H��OQU�FHo�� <br /> gRTM N <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> AsSIGNEDTO: i I.� EMPLOYEE#: DATE: In O <br /> Date Service Completed (ifaiready completed): SERVICE CODE: /\ to O <br /> _ V(p , P/E: 2 <br /> Fee Amount: "-. , Cry Amount Pail <br /> - - �5�.UD Payment Date / <br /> Payment Type i Invoice# C ck# Rec ived 6 <br /> q79`f - 13 y: <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod)CC <br /> Vce-,"— <br />