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SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH DEQ ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ^/1 )* l -�- Z3 V-cv-71 `6 <br /> OWNER/OPERATOR Ad ' <br /> �!0 IV JQ CHECK If BILLING ADDRESS E] <br /> FACILITY NAME �(A/ // <br /> ITE ADDRESS ' <br /> rW kZ N L �U �STuC IC-�c ' ��� ( 6 <br /> G Street Number Direction Street Name CI Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> -CITY STATE ZIP <br /> PHONE#1 EXT. APN# , \ LAND USE APPLICATION# <br /> PHUT 2 r ^C / � ` BOS DISTRICT LOCATION CJDDE <br /> F C r- 0 <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 laws. <br /> APPLICANT'S SIGNATURE: �1�j _ 44 CC. D E: 3 <br /> PROPERTY/BUSINESS OWNER❑ 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 asses smP T <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is pr <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �pr, Cwt~ s MAR-2 5 2 15 <br /> COMMENTS: SAN JOAQUIN C UNTY <br /> ENVIROMEN AL <br /> HEALTH DEPARI MENT <br /> ACCEPTED BY: ��4i - EMPLOYEE#: DATE: 7f <br /> ASSIGNED TO: 6L VVI P-'V-['(� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: C L, <br /> Fee Amount: Amount Paid :: - Payment Date <br /> Payment Type Invoice# Check# Received By: r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />