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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rA -3--? 1 - 0D-90 `:35:� <br /> OWNER JOERATOR <br /> CHECK if BILLING ADDRESS E] <br /> t <br /> FACILITY NAME <br /> SITE ADDRESS -7�LI � � 1��✓�;�C 1/� � —t�n/i � S�� <br /> Street Number Direction Street Name 1 city Zip Code <br /> HOME Qr MAILING ADDRESS (If Different fr Site Address) <br /> 'O�/ l% ` r� Street Number t !A, Street Name <br /> CITY STATE ZIP <br /> CCC�G V1 L <br /> PHONE#1 EXT. APN# L.AND USE APPLICATION# <br /> (50) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> `i1�ch e�� � s ��>� r3n� <br /> HO E or MAILING ADDRESS 99 , FAX# <br /> CITY �y STATE ZIP UL( l_ I <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 WS. <br /> APPLICANT'S SIGNATU DATE: D�J— 0 -7- /6( -PROPERTY I BUSINESS OWNER OPERATOR/MAN ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT S not th Y, ,,of of authorization to sign is required <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the sa l MEN((/ided to me or <br /> my representative. ` YY��aa''���� <br /> REISEIVED <br /> TYPE OF SERVICE REQUESTED: �(JQC Cb <br /> COMMENTS: JUL <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Y _ • V1 o v A EMPLOYEE#: DATE: <br /> ASSIGNED TO: u LAY-\ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: t i . PIE: �Q•Z <br /> Fee Amount: `9-2 00 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 />