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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> Ov/JStele 7� br7 L1LlZ 4:3�z031gS12� <br /> OWNER/OPERATOR I <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS `l,`I/vI/i+'t , <br /> 5/treett Number DirCecction L' Street Name "ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) I L L i PC L.J v. <br /> Street Number Street Name <br /> CITYD LU,' C ITL' $T/1� ZIP �y CI I`I <br /> PHONE#111 EXT- APN# LAND USE APPLICATION# <br /> *50) t4 q . $a-S 1 F5--+N002- <br /> PHONE#2 EXT- BOS DISTRICTLOCATION CODE <br /> � � S � - 00f vl <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUOR <br /> TJOA ^^1)� I_ N f CHECK If BILLING ADDRESS <br /> BUSINE�NIINflrr�r� CV�i �J^� b PI-P # EXT, <br /> HOME or MAILING ADDRE r/ FAX# <br /> - ,9- 6o Ca n/hto5L c ) <br /> CITY GN PSTE <br /> O <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 DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r�� I s-- j <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT iS n0 the BILLING PARTY,proof of authorization to sign is required Tire <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 sanLAme it is provided to me or <br /> my representative. / J �1 <br /> TYPE OF SERVICE REQUESTED: L�.S 7 ��j ` <br /> COMMENTS: �� � <br /> ACCEPTED BY: .t'�np/� EMPLOYEE#: DATE: JI <br /> ASSIGNED TO: ve- V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 23/ P/E: <br /> Fee Amount: I G>2 DID Amount Paid V52 ,c1f) Payment Date $ )7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />