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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F•1� a0 / � 7�c� � 12 0b 7 al'737 <br /> OWNER/OPERATOR <br /> C,I k-*V^('A Vl CHECK If BILLING ADDRESS <br /> FACILITY NAME 0bl <br /> SITE ADDRESS C G�,�,t �� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number St <br /> ee C me w <br /> CITY STAT ZIP <br /> 1 ear °IszU�P <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> sem( �ag ---►�� --�3�cD <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> C 'RU—' 1 L1 'tp A/� /jf 1^ CHECK if BILLING ADDRESS <br /> BUSINESS NAME I `11 n`�j✓ r w , l PH NE# EXT. <br /> L-(>x ovV y`C -11 U—(P 9,q Lp <br /> HOME or MAILING ADDRESS �o FAX# <br /> sca <br /> CITY STM ZIP 17 <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 a pATlication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, E Qnd FEDERAL W _- <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER HER 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 provjed to me or <br /> my representative. II�� <br /> TYPE OF SERVICE REQUESTED: �� CJ h , 1 P _6 <br /> COMMENTS: C V l!A V\Oy 0�- ��` I ✓ C��O �o <br /> y�l�R ti�itic 1Q,8 <br /> �FA�FtiO�N <br /> ACCEPTED BY: �/�/� ,\,/tO J EMPLOYEE#: DATE: ` H <br /> ASSIGNED TO: �"JV w EMPLOYEE M DATE: D_ 10-4 <br /> Date Service Completed (if already completed): SERVICE CODE: �� ` P/E: 1(1 0 <br /> Fee Amount: (CMZ a) Amount Paido IS U� Payment Date <br /> Payment Type Lz� Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />