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SAN JOAQu1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oa /►OLMe. fttc,t;r N e I-'-) I,c7 <br /> OWNER I OPERATOR <br /> � � 1 ` <br /> FACILITY NAME r CHECK If BILLING ADDRESS <br /> i A LAW 1 CJ �J12 VY <br /> SITE ADDRESS l- �L,�, _J��� l,,(�`� Sl �� t�;��✓�' <br /> •� lJ// 1 r/vl Gr V 1 U <br /> Street Number Direction r Street Name= CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> D Street Number Street Name <br /> CITY I STATE ZIP <br /> rr 5Z/3 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (ZOV blgl - y797 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (Zo9) 310- 70(a7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ /y 1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> r -, <br /> HOME or MAILING ADDRESS 'Po FAX# <br /> L ( ) <br /> CITY �.{ 1"� STAT ZIP -/SL�I Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned pr erty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRON TAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified is form. <br /> I also certify that I have prepared this application at th or be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an AL I _ <br /> APPLICANT'S SIGNATURE: DATE: &Zll Zon <br /> PROPERTY/BUSINESS OWNER L'! OPE O / ER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLI G ARTY roof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFOR ATION: 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 provided10 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: F-00It <br /> k' L—I -K <br /> COMMENTS: Y <br /> ti V'10A. <br /> C <br /> Eq�Ty�O�qNOUN <br /> 4 <br /> ANT <br /> ACCEPTED BY: �/� EMPLOYEE M DATE: <br /> ASSIGNED TO: �/' EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C P/E: <br /> Fee Amount: DU Amount Paid `� U Payment Date Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />