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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 l{ l A <br /> R%f �--j-� - �/y� ���LO� <br /> FACIUTYNAME CHECK If BILLING ADDRESS`� a.\rl �� <br /> SITE ADDRESS S OCP1� V 1 75-:26 S <br /> Street Number Direction �ren�f Namn r:r„ <br /> HOME OrAli ING A DRESS (If ifferent from Site Address) <br /> __ 9 6k <br /> Street Number CIA–Street Name <br /> CITY.— STATE ZIP D <br /> PHONE#1EXT. APN# LAND USE APPLICATION# <br /> (,-�e9) �a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> Y� J CHECK If 61LLING ADDRESS <br /> Buss SS AMEL`� PHONE# EXT. <br /> OM M ING A ISS C:) FAX# <br /> e C- ( ) <br /> Cl STATE CA ZIP 915 <br /> BILLING ACKNOWLEDGEI'tfENT: 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 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: /Q DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 asse4�*'V�O%Nl7bj <br /> matron <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Imy representative. noonN <br /> TYPE OF SERVICE REQUESTED: <br /> f'UU W flI !tL 16 CO-`l J v1 I hon 91 I Nes <br /> COMMENTS: <br /> NA1.30_3 <br /> b'd <br /> ACCEPTED BY: ArcOa <br /> ao c /i EMPLOYEE#: DATE: G <br /> ASSIGNED TO: I,ev, a, <br /> V EMPLOYEE#: DATE: 1 /! <br /> Date Service Comp eted (If already completed): SERVICE CODE: sC�� I P/E: ^U <br /> Fee Amount: �) �(,� Amount Pa18 :fir �'� �� Payment Date <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />