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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -�-Z I <br /> OWNER/OPERATOR �Q (� �/� / - <br /> { CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Name -ity Zip Code <br /> HOME or MAILING <br /> QADDRESS <br /> /(If <br /> �/Different from/_site Address) f G <br /> 1 2 L( ( C C9(00`'�CC•6A VA,� ` k� �r� Street Number Street Name <br /> CITY /' e,(C� V�—\ J-a� STATE ir; Lr ZIP C7 � . 0 <br /> PHONE#1 C./ ExT. APN# LAND USE-APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT C. LOCATION CODE <br /> ( ) J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �/� ( <br /> \, � � VrC� CHECK If BILLING ADDRESS <br /> v✓` PHONE# Ext. <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS (O ��II _� G t J �^ ` l -yam FAX# <br /> CIN SGlG� STATE -h ZIP '724;;-9-3 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f 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 a5 It IS available and at the same time It Is provided t0 me Or <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: �Jcs-t,cc_ P (ot �, <br /> COMMENTS: <br /> ACCEPTED BY: (�\.rEMPLOYEE#: 62,f c) DATE: <br /> ASSIGNEDTO: EMPLOYEE#: qO yC DATE: S /-3/) 5 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: .- -703 <br /> Fee Amount: $ S qQ Amount Paid 3 O(p Payment Date c-11 <br /> Payment Type �b Invoice It Check# Received By: <br /> o3�z5C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />