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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 007/ <br /> OWNER/OPERATOR <br /> L CHECK If BILLING ADDRESS <br /> FACILITY NAME _ <br /> L1 5 13 T F- c -T <br /> SITE ADDRESS CSL [ v, Ill <br /> Street Number Direction5 Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> X13 13 v Street Number Street Name <br /> CITY STATE ZIP <br /> L Cq 515 .33 o <br /> / PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (: b IIL 23 003 <br /> PHONE#2 EXT. BOS DISTRICT <br /> LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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 TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Zl!r- <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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time It Is �dw to me or <br /> my representative. // <br /> TYPE OF SERVICE REQUESTED: (—'A V-� A t,Z k-Q- EL J !b <br /> COMMENTS: p ,J -4V JOA 4C <br /> e, Alt y fN 1 001t COIJ <br /> Nr <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: t4 ( <br /> ASSIGNED TO: l t pK� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �.� PIE: �3 <br /> Fee Amount: o" Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />