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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ✓ 4 ��/ �� /� <br /> SITE ADDRESS i)"lv' - /� t / C' b lC1 i V'� q S�Ca <br /> JI 6� Street Number Direction V�1 5tr�ee Name C�i�c' Zip Code 1 <br /> HOME Or MAIILING/AD(D;RESS (If Different fr m Site Address) <br /> �� 1 tStreet Number Street Name <br /> CIT STATE ZIP <br /> aLA ��� c=� e <br /> PHONE#1 EXT. APN# i LAND USE APPLICATION# <br /> (-)07) ?'729- j&5-3-0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR 7eq <br /> REQUESTORI 1p <br /> • � CHECK If BILLING ADDRESS <br /> BUSINESS NAME y �j�J,���/ <br /> pun Nf# EXT. <br /> HOME Or MAILING ADD <br /> , <br /> CITY-� 1<1-04 Cv S > sTB7 zIP s <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 end that the work to be pei ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST aid FEDERAL laws. ` <br /> APPLICANT'S SIGNATURE: �( — DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGi� ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PAR iY,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/y✓�I �❑yt Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It l�pl i <br /> my representative. FCF <br /> TYPE OF SERVICE REQUESTED: lam"r C ti(� f—G(,f ( OCro <br /> COMMENTS: SAIV <br /> HE 1NV ROuZ COUN <br /> ALTH DCPA NTAI_N <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DA1E: lU <br /> ASSIGNED TO: f pa ^,��.� al"ve EMPLOYEE#: DATE: I l!!/1 s <br /> Date Service Completed (if already Completed): SERVICECODE: �O� P'/E: <br /> Fee Amount: ( ( 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 />