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SAN JOAQUIN ,FOUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY _ r i Q/7' - _ <br /> f c �J <br /> SITE ADDRESS /� r �^ LLL��J�/���(�� <br /> 730 Street Number D r�on I rc�e�tYJa `l �� toe C �v �t oC de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) )o��j��( �`�(J <br /> / Street Number e SCreet ETame l <br /> Cily STATE <br /> 6 � � a <br /> PHONE#1 EXT. APN# ND USE APPLICATION# <br /> N-7�2 7f�)o 6 <br /> 0 - -J <br /> PHONE#2 EXT. BOS DISTRIC LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> -� rr <br /> BUSINESS NAME j PHONEDt <br /> HOME or AILING AD RESS V AX# / S <br /> 4aq ��� ( ) <br /> ITY Sty 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 /> also certify that I have prepared this application and that the W_Qrk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE O fad7-1 <br /> n / <br /> APPLICANT'S SIGNATURE: /' DATE: 7 1 L'��� <br /> PROPERTY/BUSINESS OWNERPE ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not U73 ILLING 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ] <br /> COMMENTS: 0 VFD <br /> CACI yA c- G � O>, )n'� 5 1 %✓O C ?8 01? <br /> F�► � ✓�0 U/N C U <br /> �TyO �lV NAY <br /> FNr <br /> ACCEPTED BY: EMPLOYEE#: DATE: / —7 <br /> ASSIGNED TO: l v b(- �� EMPLOYEE#: DATE: / _ -_/—2 <br /> Date Service Completed (if already completed): SERVICE CODE: Q PIE: <br /> Fee Amount: c'L" 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 />