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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 /> j r Y1 L` CHECK If BILLING ADDRESS <br /> FACILITYINA�M�"-�- `A t)��E <br /> SITE ADDRESS \GrC (ASZ o-7 <br /> t <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILINGADDRESS (If Different from Site Address) <br /> Euro Street Number W Street Name <br /> CITY STATE CI\ ZIP q5-1 <br /> 1 G�f <br /> PHONE#1 EXT. APN# LAND USE APPLICATION#i "` l l!"1 <br /> 1000l`1k 5�3y �I vim` <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 7a) <br /> � +^ CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME' E# EXT. <br /> �\ w � Kc-fi� �0W,, -1 <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 a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: yb u(k'� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEfj>E] 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. Q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> S�p�t CGl('(-L.ISZ�O CS ENVf OST <br /> C <br /> ?018 <br /> PERM/ SFR t HRCT <br /> ACCEPTED BY: r7i EMPLOYEE#: DATE: <br /> ASSIGNED TO: U )- S C EMPLOYEE#: DATE: p a /O <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount.�. , ({J- C[�r Amount Pai CiL�/ V Payment Date 5Z$ / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> pkev� <br /> -� <br />