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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> �a � I Fkt' 574 le9 A aa, z j Li S VV <br /> P ") � 1 <br /> OWNER / OPERATOR 7 <br /> :fct� wA CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME ! 7 % 9 5wafthay Fk W Can t <br /> SITE ADDRESS 952Dgi- <br /> 26 M Street Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 Ex r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR - � A . I <br /> bttw CHECK If BILLING ADDRE <br /> BUSINESS NAMEGim �„r(,� PHONE # EXT, <br /> 11 __ <br /> HOME or MAILING ADDRESS <br /> Q� Q FAX # J/ <br /> CITY ✓f 1D /PCAAC STATE &JA ZIP 11 <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, Standardl STATE and FEDERAL laws , <br /> APPLICANT'S SIGNATURE : 9DATE : - l `r - "�- D � <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 propertyQ� t the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site aSrtY tion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It a or <br /> my representative , <br /> TYPE OF SERVICE REQUESTED : u %21V elSq 9 <br /> COMMENTS : <br /> or W09 <br /> NF,yFNI/ OVIN O <br /> tTHFDpgR t <br /> e <br /> ACCEPTED BY: A0000tU EMPLOYEE #: DATE: <br /> ASSIGNED TO: EMPLOYEE #: DATE: 22 <br /> Date Service Completed (if already completed) : SERVICE CODE: O PIE; <br /> Fee Amount : ���' Amount Paid S Payment Date <br /> Payment Type 000 — Invoice # Check # 41 � t7 9 � L� � 5 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br /> I <br /> I <br />