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SAN JOAQU�.. vOUNTY ENVIRONMENTAL HEALTH L-.-ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N�iw S�.00��0�5 <br /> OWNER OPERATOR I <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> y � <br /> SITEADDRESS �✓JI <br /> I 1 � Street Number Direction Street Name V' �I/ Zi Code J <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PH NE'1 , /,/ EXT• APN# LAND USE APPLICATION# <br /> PHON #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME ��J V V PHONE# EXT. <br /> �� <br /> HOME or MAILING ADDRESS-7 FAX# <br /> {\� O (2 ( ) <br /> CITY C d �5�3 63 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 19 <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time� r vided to me or <br /> my representative. y rM <br /> TYPE OF SERVICE REQUESTED: o (G(� J 1 e&( O rl <br /> COMMENTS: 074 Y <br /> 11, 2164 �Y <br /> ` r 'SENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1� <br /> ASSIGNED TO: (� EMPLOYEE#: DATE: Z /I <br /> Date Service Completed (if already completed): SERVICE CODE: SC U I P 1 E: <br /> Fee Amount: I Amount Paid Payment Date <br /> Payment Type Invoice# Check# Z7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />