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I <br /> SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 rj1 <br /> OWNER I OPERATOR <br /> S 0Pig <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME i N l ()/� (`Kt. — <br /> SITE ADDRESS s C L_ P-"� S R S7�S <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (IffDifferent from Site Address) <br /> V r N Iy D _ Street Ne.-6er Street Na-- <br /> CITY Q STATE ZIP , <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> A-W 510,-7 G 19 l -4t lip Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATIpN CDDE <br /> Q101) q I S7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �C— L� PHONE# EXT. <br /> HOME or MAILING ADDRESS G FAX# <br /> LA 8 L ( ) <br /> CITY � / STATE ZIP t� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned aroperty or business owner, operator or authorized agent of same, <br /> ar,rno,,,;ledgc that all Site Gild/Or project Specific EN'VIRONIvi--iJTAL HEALTH DEPARTMENT hourly Charges associated wltn 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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, <br /> S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE T 5 <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same time It is provided t0 me or <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: ��� U.� L RE T <br /> COMMENTS: D <br /> Fe202 <br /> 0SqNog4( l�v EyVOFlACM14c4rh TC <br /> ry <br /> ACCEPTED BY: �t��� Z EMPLOYEE#: DATE: <br /> ASSIGNED TO: W El+1PLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: b6 t PIE: p <br /> Fee Amount: t 3 p Amount Pai 130e5D Payment Date 5 <br /> Payment Type Invoice# Check# Received By f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />