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y <br />! SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-Do <br /> OWNER I OPERATOR <br /> AJAVJaT CHECK if BILLING ADDRESS 13 <br /> FACILITY NAME I / i <br /> / f I(.J/t <br /> SITE ADDRESS 22treetNumher Cad <br /> Cot <br /> SDireotlon !S'ttreet ame ,Uel) 1 ZI e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I <br /> Street Number Street Name <br /> C'n STATE zip <br /> f <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( - © O© r <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( r _ IB <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME + PHONE# ExT. I <br /> I <br /> HOME or MAILING ADDRESS Fax# <br /> I ( ) 3 <br /> CITY STATE ^ ZIP <br /> BILLING ACKNO GEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all S ndlor project specific E=NVIRONMENTAL 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 d EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERA /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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the same time It Is provided to me or I <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: U f �� "f Y <br /> i <br /> COMMENTS: <br /> �W 4� <br /> C) S�N,,b �Zoos <br /> a17'1 avzq�AFNrqU H <br /> ACCEPTED BY: /) f��(/I EMPLOYEE#: DATE: <br /> t�L <br /> A551GNED TO: vv vv�t Mellba, r EM PLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: X60LI I PIE: Z <br /> Fee Amount: 3 Amount PAID 131� OD Payment Date /O/2771�4 <br /> Payment Type Invoice# Check# 13,C71 <br /> Received By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />