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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SRVICE <br /> Eq ST# <br /> N / L 1 <br /> t/DE159 <br /> OWNER <br /> /OPERATOR <br /> ' RA DA <br /> / CHECK If BILLING ADDRESS <br /> 4A Al <br /> FACILITY NAME <br /> SITE A�D{FnREESS 5 A G�4mj4 AE1VT(� <br /> '7 J"/ Street Number Direction Street Name Citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 5 02 /" Street Number Street Name <br /> CITY STATE ZIP <br /> v dA <br /> PHONE 111 EXT. APN# LAND USE APPLICATION# <br /> " > 3- r 0 o - a19o� 1V /019G <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO E# ExT. <br /> 4 <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY // STATE ZIP ?� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property siness owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project spec! E MENTA EALTH DEPARTMENT-hoJ.g!y charges associated with this project or <br /> activity will be billed to me or my business a I le s f <br /> I also certify that I have prepared this appl' I d at the work to ed will b in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST E- nd F R ws. <br /> APPLICANT'S SIGNATURE: A DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/M NAGER ❑ O"HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of author' ation to sign is required Tirle <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 t0 me or <br /> m;,representative. <br /> TYPE OF SERVICE REQUESTED: E kQ /94 P <br /> COMMENTS: <br /> I <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already comple ed): SERVICE CODE: P I E <br /> Fee Amount: Amount Paid 0 __ Payment Date <br /> Payment Type Invoice# Check# 3�' 7 Received By: <br /> EHD 48-02-025 � � �'�.A^:� \''k7 ( vI I C SR FORM(Golden Rod) <br /> 07/17/08 1 <br />