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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (Z v C \L 001 SO 7`, 7 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS .2� �� City <br /> Street Number Direction 1'F Street Name n Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 C) S I I r�1 2 e �2 do � V-V <br /> Street Num'.,er Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (201� (009- z SS$ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ.IESTOR — – <br /> A..)� ( Jv!�` CHECK if BILLING ADDRESS <br /> BUSINESS NAME / /"-,a � (� -8( I/ HOE F/'- <br /> HOME or MAILING ADDRES§ + �� FAX# <br /> t <br /> LSD 1 C� V %cam �L"� ( ) _— <br /> CITY STAT �1— 71P <br /> 2!'—LIN, ACKNOWLEDGEMENT: I, the undersig,ied property or business owner, operator 7,r authorized agent of same, <br /> acknowl,-:doe that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will je billed to me or my business as identified on this form. <br /> also certir,1 that ! have prepared this application and that the work to be performed will be done in accordance .'Vitl- all SAN JOAQUIN <br /> COUNTY OrCirance Codes, Standards, STAT d FEDERAL laws. <br /> j <br /> APPLICANT'S SIGNATURE: DATE:jZ -lY l <br /> PROPERTY/BUSINESS OWNER ElPERATOR/MANAG OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT IS not the BILLING PARIY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When app icable, I, the owner or operator (f 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 ii1formatiorl <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 /> TYPF OF SERVICE REQUESTED: <br /> COMMENTS: C <br /> Gl�t�t t 1 ti z c� CTL-v n C� <br /> 1 4 '(-66 <br /> SAN JOAQUIN COUN <br /> ENVIROMENTAL <br /> 1iEAL1 H DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGi,IED TO: r\\ e S EMPLOYEE#: - DATE: IL <br /> Date Service Completed (ifl already Completed): SERVICE CODE: G PIE: i 7 •.� <br /> Fee An.ount: 130 -- Amount Paid 13 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />