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SAN JOAQG,.. COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � . wic) is2 <br /> OWNER/OPERATOR <br /> u�1 (Z � t1 ` AAA ) ❑ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME /o <br /> SITE ADDRESS I ^L /�, ^ 01G2D-!) <br /> Street Number Direction Street Name <br /> HOME Of MAILING ADDRESS (If Different from Site Address) ZI' ` ' e�1- _C( n ��,�1 n� <br /> Street Number V " Y��/ i'Sttre'et Name, +r=, <br /> CITY * vk �� STATE G zip �-bo/lI <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# '� <br /> 210— of 1p 2 e <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> Q1 2�'0 -S�'1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR o Y lV,I- <br /> AG CHECK if BILLING ADDRESS <br /> BUSINESS NAME I �,r nA 11 a C P ()NE# 1Q_l14-77 ExT. <br /> HOME Or MAILING ADDRESS ,"✓ l^ Q � ^ _n SAX# � J <br /> CITY S�-o/ k)ro� VSTATE C zip 0`C <br /> BILLING`,ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagent 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 fII <br /> cation nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,SE and F laws. n <br /> APPLICANT'S SIGNATURE: 4DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANP IS nOt the BILLING PARTY,proof of authorization to sign is required Ti11e <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It I vlded to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: fj <br /> COMMENTS: <br /> so <br /> �qN <br /> ACCEPTED BY: I,/fj O jl EMPLOYEE#: DATE: <br /> ASSIGNED TO: p/I Y/, V EMPLOYEE#: DATE: vIO��Vi 1 l—I <br /> Date Service Completed (if already completed: SERVICE CODE: Do I P/E: I�� <br /> Fee Amount: IG�Z Amount Paid Payment Date <br /> Payment Type -I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />