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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 /> I N 1 r M` /U CHECK If BILLING ADDRESS <br /> I FACILITY NAME 1 l / l <br /> SITE ADDRESS ,S � l f n I <br /> Street Number Direction /v Street Name V"I VCit C A 1 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �„ _n <br /> l , , _ \ 4-t(� CHECK If BILLING ADDRE <br /> J V Exr. <br /> BUSINESS NAME ') �L CJ n f �� ` / Av�l n__ ,�(�rn PHONE# O ', <br /> HOME or MAILING ADDRESS 1 _ FAX# <br /> CITY I /` STATE ZIP <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. f� <br /> APPLICANT'S SIGNATURE: "4— DATE: f ���U <br /> PROPERTY I BUSINESS OWNER J�1 OPIERATO 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 s .i�pr�vlded to me or <br /> my representative. rfj CC1ry1 �' <br /> TYPE OF SERVICE REQUESTED: �d U <br /> KhCWVftU <br /> COMMENTS: rr MAY 2 1 20% <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: p h ( EMPLOYEE#: DATE: C 2 ._ /y <br /> ASSIGNED TO: oto 4� n EMPLOYEE#: DATE: J� r D/ <br /> Date Service Complete (if already completed): SERVICE CODE: '0(01 P/E: I�-I <br /> Fee Amount: , -ZtPU Amount Paid 5 Payment Date a I I1$ <br /> Payment Type C S h Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 �b e jet kQ v• ct5yii <br /> l`vgo 16 / r v e sT <br />