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3i c SAN JOAQUIN C- LINTY ENVIRONMENTAL HEALTH Tl PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CAPS '5T-KK'i P� 00 t�;/ <br /> OWNER/OPERATOR r <br /> O CHECK If BILLING ADDRESS❑ <br /> FACILITY NAJ <br /> SITE ADDRES % 7LW C� Wl IAA(�,t (4 e- gSd 6 y <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING A'ITS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. N# LAND USE APPLICATION# <br /> *V 9�� -y� Q ' AP07 1 a 80--0 1 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CbNTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> q1te _ <br /> BUSINESS NAME ( I PHONE# Ext. <br /> IM A <br /> ��V11 �� PfF <br /> OME or MAI ING ADDRESS FAX# <br /> CITY STATEJN ZIP q <br /> BILLING ACKNOWLEDGEMENT: I, thAied ed property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speciENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business athis form. <br /> I also certify that I have prepared this applict th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST ELAPPLICANT'S SIGNATURE: r ' DATE: 2 K <br /> PROPERTY/BUSINESS OWNER OP MANAGER ❑ \DEPART <br /> RIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPARa proof of authn is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When apowner or operator of the property located at the <br /> above site address, hereby authorize the release of any and allhnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: V4gwe4� RECEIVED <br /> COMMENTS: q DEC 19 2008 <br /> SAN JOAQUIN COUNTY <br /> o ENVIRONMENTAL <br /> X HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): (7�V SERVICE CODE: <br /> Fee Amount: ��' Amount Paid 3 `S v Payment Date 1 6 <br /> Payment Type Invoice# Check# By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />