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SAN JOAQUIN'160UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> om;`; =HECK If BILLINGADDRESS <br /> NAME ' 1 rl. <br /> SITE ADDRESS tr mber DRESS (�\/,\r��r�{�� 1'1 Tl ri Cr � G�6 <br /> nn <br /> � Direction SSC of aLme�J vim]•, CI I �Z�ito CJo�tle� <br /> HOi.'E or kf aIUNG ADDRESS (If Different from Site Address) <br /> (/2 SV«tNumber 5[edtNa �J <br /> CIT, O,ra STATE ZIP <br /> PHONE#1 `( \ Ex. APH# LAND USE APPLICATION# <br /> PHONE#2 EXT. J DISTRICT LOCATION CODE <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME (�\ PHONE# Ems' <br /> i <br /> HOME or MAILING AD KESS FAX# <br /> ( ) <br /> CITY /} m STATE 4 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 wercio4e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard A d FEDERAL la . <br /> APPLICANT'S SIGNATURE/\ DATE: <br /> PROPERTY/BUSINESS OWNER0.//� OPER OR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ _ <br /> if APPLICANT IS not Lhe BI NG PARTY, AGER <br /> Of dNft1011iatlOn f0 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: o AY14! r <br /> COMMENTS: nCL; 'V D <br /> JUL 11 20 <br /> SAN JOAgU1N CO <br /> ENVIROMENTq Nry <br /> HEALTH pEpART <br /> ACCEPTED BY: J I EMPLOYEE#: DATE: <br /> ASSIGNED TD: v/]/, Q(f n EMPLOYEE#: DATE: -7111 <br /> WY/I h n <br /> Date Service Completed (if already completed): S .�r„n7 <br /> SERVICE CODE: coleI PIE_ j / <br /> Fee Amount: D Amount Paid. - Payment Date lY�'� <br /> Payment Type Invoice# Check# Received By: i <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />