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Y SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTHISPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUf ST# <br /> P,S 0� 003 _,5J(a156 019 <br /> OWNER/OPERATOR <br /> S • CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> �tfC) <br /> SITE ADDRESS <br /> Street Number I Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (ifDifferent from Site Address) <br /> Street Number <br /> Street Name <br /> CITY C STATE ZIP (j <br /> CA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# �7— <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> a ' W CHECK if BILLING ADDRESS <br /> BUSINESS NAME _ <br /> Serie vt 5 t:t(t T JEP-tc a t--3-bc3 F EXT. <br /> HOME or MAILING ADDRESS Fax# <br /> CITY S OL" STATE L A zip (?IT-1 !Q, <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized argent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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, STATE-and FEDERAL laws. <br /> APPLICANTS SIGNATURE: LLi,ILX ct �% l��ki� c.[ C dC-GI✓ DATE: tl t,-iq 14�6b.v <br /> PROPERTY/BVSINLSS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1/APPLICANT is nor the BILLING PARTY'proof of authorization to sign is required Tirlr , `S <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> — - <br /> TYPE OF SERVICE REQUESTED: �� �(�� RECEI� <br /> COMMENTS: -ftv NOV 2 5 2008 NOV t,.a/?iF <br /> Z 0 <br /> COVN -i- i <br /> Iv ENVIRONHEALTipEpgREMNT PET, T/�r, C( }. <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P l E: <br /> Fee Amount: ��� Amount Paid ` S Payment Date �� 2-5 <br /> Payment Type Invoice# Check# S- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />