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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -0(�6 ni;--oa- 2) �o6?na�7 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ApDRESSO <br /> e S Sa Ar. <br /> FACILITY NAME <br /> SITE ADDRESS C coven U 61M d ���-�� c6YT6 <br /> 5 StreetNumher Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS If Differeddress)rom SItA A <br /> (( � `r JJ-�� 0.C\�}t� /'/� <br /> k V L <br /> c– V C— Street Number �r ` Street Name <br /> CITY St�c�to•�. CTATE ZIP :L <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> 0,01) %3 S - <br /> PHONE#2 E-AT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR SER`6qCE R QUESTOR <br /> REQUESTOR t CHECK If BILLING ADDRESS L� <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS t, FAX# <br /> 5G 1 VEVN C A ( ) <br /> CITY tm'p w� STATE C ZIP C R <br /> BILLING AGKNOWLEDGEMIENT': I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIR ENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified this form. <br /> I also certify that I have prepared this application and at e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and AL la <br /> APPLICANT'S SIGNATURE: DATE:: 1 <br /> PROPERTY I BUSINESS OWNER ElOPERATORI AGER 1:1OTHER AUTHORIZED AGENT Elf/ e, <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 /> to the SAN JOAQUIN COUNTY ENV4RONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is provided to me or <br /> my representative, <br /> TYPE DE SERVICE!REQUESTED: <br /> COMMENTS: J <br /> D <br /> G a (�t�V1 �1 SAN out x 8 zed <br /> �� �'� NE�fyH ROME O NrY <br /> DEP, A <br /> ACCEPTED BY: EMPLOYEE DATE: ^7 <br /> NT- <br /> ASSIGNED TO: J� � �rn EMPLOYEE: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0/10 PIE: 1 �� <br /> Fee Amount: ' Amount Paid �30.dD Payment Date 7 !�/ <br /> k ! <br /> Payment Type V�� invoice# Check# 115�`�J� Received By: <br /> EHD 48-02-025 SR FORME(Golden Rod) <br /> 07/17108 <br />