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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 Q. WD52. <br /> OWNER/OPERATOR <br /> Q l t \ aY �� <br /> ^ CHECK if BILLING ADDRESS <br /> FACILITY NAME ` `• l' <br /> S raAJJ Cie <br /> SITE ADDRESS ",7 I I C�) 'n �� ` � qS c�,1 <br /> Street Number Direction 1� Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY; � STATE ZIP ^O I I <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# L Vt <br /> ( vim) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> -� CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / CHECK If BILLING ADDRESS O <br /> �V1\b G a Y c�at- <br /> BUSINESS NAME `\{ck,� C�.vice PHONE# EXT. <br /> VJ 7 - 333 <br /> HOME or MAILING ADDRESS FAX# <br /> 2t t IS ( ) <br /> CITY � � STATE c 11 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 /> 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 haws. <br /> APPLICANT'S SIGNATURE: 2jQ, `` 7 iGL DATE: �JC�X215 1 a <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 assessmen Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provl� g or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: P;11�1 <br /> COMMENTS: ^n C�J n %J <br /> � 20 <br /> ++ E��gQUll y C <br /> `A KT ( "�cTy�E qR �N <br /> II <br /> ACCEPTED BY: M ,(� } EMPLOYEE#: DATE: <br /> ASSIGNED TO: rA \, (-51--V , EMPLOYEE#: DATE: J <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: 1 D <br /> Fee Amount: Amount Pai Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 �I` �`�� 0;41N 0 SR FORM(Golden Rod) <br /> D7„x,08 <br />