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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FF�oc r�q� bb-7S-11a4 <br /> OWNER/OPERATOR <br /> WAVA n CHECK If BILLING ADDRESS� <br /> AD <br /> FACILITY NAME ��/ <br /> 13 lcF� , <br /> SITE ADDRESS <br /> Street Number DlrecUon Slree ame Ci •f ZI Codey <br /> HOME or MAILING ADDRESS (If Different from Site Address) DCI � �..!— <br /> _ .Number "1,�,1.p Street Name / <br /> CIN STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> Q-9) - 70 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( �9) 0- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ANA <br /> A IZ I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Q EXT. <br /> AS <br /> rMARVel o' <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY L,2 I I STATECA <br /> ZIP SA � <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 /> 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, STATE and FEDERAL laws. / �J <br /> APPLICANT'S SIGNATURE: LAJ 681? AWAD DATE: <br /> PROPERTY/BUSINESS OWNER® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tine <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: byl <br /> COMMENTS: <br /> JAN 16 201 <br /> SAN JOAQUIN COUN <br /> HALT IRONMENTAL <br /> H DEPARTMEA T <br /> ACCEPTED BY: EMPLOYEE#: DATE: ' _ / , /9 <br /> ASSIGNED T EMPLOYEE DATE: <br /> Date Service Completed (ifalreadycompleted): SERVICECODe PIE: <br /> Fee Amount: 1 r Amount Paid i' Payment Date <br /> Payment Type / 1 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />