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SAN JOAIKVIN COUNTY ENVIRONMENTAL HEALTI. .DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> Gro cu St�r F4 tD D 44 � -Skrnl?0191 <br /> OWNER I OPERA'IrOR - <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME p I L O n_ ` ' b (1 ^ , K _..r <br /> SITE ADDRESS F33q 1- 6v� ll ll '��hlI <br /> Street Number Dlrectlon Street Name CI ZI Code <br /> HOME or MAIL//I�ANG ADDRESS (If Different from Site Address) <br /> 1935'"I W / Street Number Street Name <br /> CITY STOP-TSN STATE zip <br /> q-5- (S <br /> i <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> (20 66)- - 0350 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK IT BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( I <br /> CITY STATE IAP <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 wo k 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: (0L23I )-b17 <br /> PROPERTY/BUSI N ESS OWNER Uf 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 /> 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. <br /> TYPE OF SERVICE REQUESTED: Q 6,Kfl I fr&6f) 11 <br /> COMMENTS: t +0 L✓t zcG WGfV aLr 44(0 116t'6 t' <br /> 191% J <br /> N�7tyi <br /> ACCEPTED BY: T arZl =EMPLOYEE#: � DATE: <br /> ASSIGNED TO: L h EMPLOYEE M DATE: <br /> Date Service Completed (if (ready completed): SERVICECODE: ( PIE: <br /> Fee Amount: ` Amount Paid /�d,dU Payment Date / / "(p l73 <br /> Payment Type Invoice# Check# Sb 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />