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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />C -- <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />RVICE REQUEST # <br />HOME Or MAILING ADDRESS ' I I <br />0(b✓j GI <br />FAX# <br />t ) <br />CITYb <br />G STATE CA ZIP —95-90 <br />OWNER /OPERATOR G <br />ASSIGNED TO: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME �'� j ��� J✓S� <br />DATE: <br />Date Service Completed (if already completed): <br />SITE ADDRESS 9376 <br />SERVICE CODE: <br />23 <br />S� a' <br />Rz,&,J <br />Amount Pa <br />Tri C L <br />953o U <br />Street Number <br />Direction <br />Street Name <br />Recei ed By: <br />Ci <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />cl /_n "76 <br />/Number <br />7 <br />street <br />Stree Name <br />CITY J�+ <br />STATE //61 ZIP <br />/ XJ <br />PHONE #1 EXT. <br />APN # <br />WD._ F7 <br />LAND USE APPLICATION # <br />?]�( <br />6) -0-7 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR j <br />, / SC l l CHECK if BILLING ADDRESS E] <br />F6 <br />(J1V (((,����( <br />BUSINESS NAME <br />Si e \e \ <br />PHONE# �� J� EXT. <br />HOME Or MAILING ADDRESS ' I I <br />0(b✓j GI <br />FAX# <br />t ) <br />CITYb <br />G STATE CA ZIP —95-90 <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, =ST;IJFEDERAL laws. <br />APPLICANT'S SIGNATURE:�r� DATE:�f <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 assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the Same time It IS pr ded to me or <br />my representative. <br />9�,qInA.A <br />TYPE OF SERVICE REQUESTED: , <br />t!? ,es <br />COMMENTS: <br />O �IrjvJJ <br />�� <br />-Ick IYV 142 <br />ti FNSQ�,N 9 <br />TyOFpq FT OU o-)' <br />ACCEPTED BY: <br />EMPLOYEE #:o <br />DATE:% <br />vv <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />dl <br />SERVICE CODE: <br />23 <br />P15: <br />(�ZD <br />Fee Amount: <br />` <br />Amount Pa <br />3D <br />Payment Date `�` <br />Payment Type �� <br />Invoice # <br />Check # <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />IJ <br />