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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> LP CHECK If BILLING ADDRESS <br /> FACILITY NAME Cr <br /> SITE ADDRESS �V I j n A n <br /> Str et u er Direc ion [YLI�, 'v te "..me Vv itv Zio-(Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Z 10 t Street Number Street Name <br /> CITY STATE ZIP <br /> PHOn NE#1 � EXT• APN#�,^ � �/t LAND USE APPLICATION# <br /> w'f <br /> PHONE#Z EXT, BOS DISTRICT LOCATIO DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S.t CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> I 6 -9Z <br /> HOME or MAILING ADDRESS FAx# <br /> ( ) <br /> CITY STATE ZIP <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. <br /> APPLICANT'S SIGNATURE: ;, v wN ri C r)Viz G I-f. Z DATE: D/ <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY.Proof of authorization to sight 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 assess menL Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provim{ Qr <br /> my representative. 4 IV76 <br /> TYPE OF SERVICE REQUESTED: 0 <br /> COMMENTS: Nps W'14 SAJV <br /> K HEALTEIVhRO�ENTO MY <br /> EPARN <br /> iVr <br /> ACCEPTED BY: EMPLOYEE#: DATE: () <br /> ASSIGNED TOCEMPLOYEE EMPLOYEE M DATE: O� <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: O <br /> Fee Amount: Amount Paid �36 D rj Payment 6ate ZZ/15- <br /> Payment <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />