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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 a.-f: -1 <br /> OWNER/OPERATOR __ <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME � �`/� �a ���•� //� <br /> SITE ADDRESS <br /> l lV/ tN <br /> C <br /> odetoNumber ion T te:ame Ci <br /> HOME Or MAILING ADDR SS (If Different from Site Address) <br /> a/-/ o`C.. Aq Street Number Street Name <br /> CITY STATE ZIP ��� <br /> G,w e c M <br /> PH #1 `` EXT. APN# LAND USE APPLICATION# <br /> (�) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> F r C7 ,` U-G CHECK If BILLING ADDRESS <br /> BUSINESS NAME ''- V` P # EXT. <br /> OA f1s tt <br /> t o t,L<,►�t eA � , r;27-7 <br /> c 4 27? - <br /> HOME orMAILING A DDRSS FAX# <br /> �t� v I CIO (d 41 ( ) <br /> CITY /) 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 /> I 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,STATE D AL laws. <br /> APPLICANT'S SIGNATURE: ,s��/t�-� DATE: <br /> PROPERTY(BUSINESS OWNE P ATOR(MANAGER ❑ OTHER AUTHORIZED AGENT El (/GU✓w <br /> I(APPLICAN Is not t:e 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 itrpv_Ided to me or <br /> my representative. �� A. <br /> TYPE OF SERVICE REQUESTED: • ,,�— <br /> COMMENTS: / 1 i <br /> s N"ogQ�/13 ,7018 <br /> y�CT��FpgRNO�N�' <br /> MEhtT <br /> ACCEPTED BY: La ICI ,C Q I trs EMPLOYEE#: DATE: INC <br /> ASSIGNED TO: NCO1 -zo EMPLOYEE#: 2 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P E: (P6 <br /> Fee Amount cJ Amount Paid 1 L f�� vD Payment Date 3/g <br /> Payment Type 011 Invoice# Check# ''71 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />