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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I (AI( c <br /> OWNER f OPEJ�RATOR <br /> PTI SL C,l' !� CHECK If BILLING ADDRESS I� <br /> FAciuTYNAME r �/ V t <br /> SITE ADDRESS t `+( �`-/��/✓�'� (�\ �t 5`✓�t9etNLmb¢r Direction / A Z l SUre tName' Cll� �ZI Cade <br /> HOMEor MAILING <br /> rrADDRESS <br /> � (If Different ffrr�om, /Site Address) <br /> ^11\ r CS �1l C't Number Street Name <br /> CITY UL��,L7-� STATE C A ZIP <br /> PHONE#1 Eu. APN# LAND USE APPLICATION# <br /> qo�) 1-1 SQ `a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C rLL� �kG � JS <br /> I\� CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAME r I PHONE# ExT' <br /> HOME or MAILING <br /> ,�P ��E Lu ger , ��' zF� 2z ra <br /> ADDRESS FAX# <br /> �s k c� Cx✓ I ) <br /> CITY /t STATE^ A- ZIP 7 S" <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 /> 1 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 /> COUNT' Ordinance Codes,Standards, STATE and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: DATE: 1'2. `-y l5 <br /> PROPERTY/BUSINESS OWNER 13 PERATOR/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 environmentallsite assessment inf Ion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provideWt <br /> my representative. r^y p syn^ �Y �I/ fV <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> FA<ly�e�N�rO <br /> nq TM <br /> ACCEPTED BY: / EMPLOYEE#: DATE <br /> ASSIGNED T0: KC ,�11r'j(� G�Ir&rZS EMPLOYEE#: DATE: •�• j y <br /> Date Service Completed (if already completed): SERVICE CODE: JC L W I I Pig: <br /> Fee Amount: - AmountPa' 130,�(� Payment Date <br /> Payment Type 61Invoice# Check# Receive By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />