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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH G. ARTMENT <br /> SERVICE 4EQUEST <br /> Type of Business or Property FACILITY IDS SERVICE REQUEST# <br /> '�-Jim I plj i ZI <br /> OWNER/OPERATOR -+ <br /> G �� J CHECK If BILLING ADDRESS <br /> FACILITY NAME I �rv� <br /> SITE ADDRESS Y'yc�P' <br /> Street Number Direction Street flame CI Zip Code <br /> HOME Or MAILING ADDRESSIf Different rom Site Address) <br /> ( J (� ')?7 Street Number Street Name <br /> CITY _ S TE 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 /> A. <br /> 'LA ;� jJS � CHECK if BILLING ADDRES <br /> BUSINESS NAME 1tr_� , PHONE# p T <br /> HOME or MAILING ADDRESS /� FAX# <br /> CITY l J ����, STYE4 ZIP C� )' <br /> -\ y <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 I s. <br /> APPLICANT'S SIGNATURE: r DATE: �� <br /> PROPERTY/BUSINESS OWNER 1:1OPERATO MANAGER ❑ OTHER AUTHORIZED AGENT ® l^ <br /> L\ R� Y/X13:V ;A lxw <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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEr{Y/ED <br /> MAY 1 1 �0-5 <br /> SAN JOAQUIN COUNTY <br /> ENWROMENTAL <br /> HEALTH DEPS-- <br /> ACCEPTED BY: yy, EMPLOYEE#: DATE: J� <br /> ASSIGNED TO: L �� EMPLOYEE#: DATE:��� �-- <br /> Date Service Completed (if already completed): SERVICE CODE: C—46"I P 1 E'� <br /> Fee Amount: C �O aJ Amount Paid Payment Date �- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />