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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a77-"' S6� Do767 Ips <br /> OW 'tR i QPERATOR: l i " <br /> -• ,�tYt^ Q HECK It'BILLING ADDRESS <br /> FACILI&YFV� - HEXIWL <br /> •C <br /> SITE ADDRESS elm I- <br /> StrectNumber Direction r .Q Nama °i~' �OnC^•'^ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> PHONE#1 1(.��� EXT. APN# LAND USE APPLICATION# <br /> PHONE.#Z r� E.-T. BQS DISTRICT LOCATION CODE <br /> v -- <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> lif'IC ri)1 if E71LLiNG Af1DRES <br /> BUSINE A fa Cln► V"-A PI-IONE# E><T. <br /> it <br /> HOME Or MAILING ADDRESS FAX# <br /> i { } <br /> CITY STATE C ZIP n OL <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 F DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r /A Z/C' <br /> PROPERTY I BUSINESS OWNER ff PERATO 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 environmentallsite assessment information <br /> to the SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is proviPa or <br /> my representative. �����A��ll// <br /> ItF <br /> TYPE OF SERVICE REQUESTED: U IV <br /> COMMENTS: SRN J i zQ <br /> tJ�vJ U+ UJ I�1C�� hEA TH DOIyF04 <br /> OO 7Y <br /> Pggr�- <br /> r <br /> ACCEPTED BY: std EMPLOYEE#: DATE: ! <br /> ASSIGNED TO: EMPLOYEE#: DATE: /� J <br /> Date Service Completed (if already completed): SERVICE CODE: C)Z ! P1 E: tip� O <br /> Fee Amount: Amount Paid I� !• v I Payment Date 12— <br /> Payment Type r Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />