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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property �FACI FACILITY IBS�I SERVE _RE��ST# <br /> AA '" l S)c 0 l ( 3-Q <br /> OWNER/ AERATOR <br /> tt."",,`"'^^__ n C//lA, a✓L� CHECK if BILLING ADDRESS <br /> FACILITY NAME 1 y�(�f�/ w/— #�-cf4- <br /> 5 <br /> SITE ADDRESS ^' L/]!�n�Street <br /> 1� (,•� ( L Iz �n C LI C� <br /> ( Street Number Direction 1'' 1, Street Name ) Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Differen from Site Address) Street J- TO <br /> Street Number a�me Z nI <br /> -e7 <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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. <br /> APPLICANT'S SIGNATURE: DATE: Q t O r <br /> PROPERTY/BUSINESS OWNER❑ 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 provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 4/01/ <br /> �o� v � <br /> 0 <br /> y�FN�Ro VVV 8 ?��� <br /> �Ty�Fp"'FC041, <br /> ACCEPTED BY: �/ja, /� SG` EMPLOYEE#: � �� DATE: i /F <br /> ASSIGNED TO: J� I^ EMPLOYEE#: qR'o� DATE: <br /> Date Service Co/m'ple ed (if already completed): SERVICE CODE: t!p I P/E: �60� <br /> Fee Amount: /soZ Amount Pai /�� �0 Payment Date A $ l <br /> Payment Type CJ11--- Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />