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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/6PERATOR <br /> A t `p <br /> CHECK if BILLING ADDRESS� <br /> FACILITY NAME <br /> sgs FrE DSs(Y�P4 }OcV--� <br /> Street Number Olrection Street Name c1tv Zip Code <br /> I HOME or MAILING ADDRESS (If Different from Site Address) 5� m���1 =LE�/S ✓ti IA L� <br /> j - Street Number 1 Street Name <br /> 1 CITYSTATE ZIP <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. B SS DISTRI LOCATION CODE <br /> v�vi) acf /�� Ci <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR iJ <br /> !/•/�{/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Yt-\ 9 SS qS <br /> HOME or MAH-ING ADDRESS �J 7 FAx# <br /> h7/cj��L�,zs wp ( 7) CCS�' 4UoLI <br /> CITY �7,/%E .gyp <br /> 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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN J0.4QUIN <br /> COUNTY Ordinance Codes, Standards, TATE and FEDERAL IaWS. lam, <br /> APPLICANT'S SIGNATURE: DAT o� <br /> PROPERTY/BUSINESS OWNER❑ QPERATOR/MANAGE ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 /> t0 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. r <br /> TYPE OF SERVICE REQUESTED: cjL1� `�.. }, C b SLtn k2-L CO li k/i i L c �/CET <br /> COMMENTS: ECEI V <br /> 0 AL� 1/q <br /> Intl �1af� .� ;,(re NOV Uz <br /> SANNJOAQUIN V ROMENTA COUNT <br /> EALTHDEPARTME <br /> ACCEPTED BY:' :]� <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: 5)Cr- 64 EMPLOYEE#: Dr TEi <br /> Date Service Completed (if already completed): SERVICE CODE: Y PIE: ��J <br /> Fee Amount: •� �p� 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 />