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SAN JOAQUIN .OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Foca T nuc FIgvDICIrL s3 15R i- 8-3y <br /> OWNER/OPERATOR <br /> Cil CHECK If BILLING ADDRESS <br /> FA��IILIN NAr,�E <br /> ( A\'ire 0. C /-VYL dr- \ ✓a. 5 r _ / <br /> �E ADDRESS S 0SZCJ� <br /> So Street Number Direction t 1`"' Str¢¢t Nam¢ �� CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) net Y-W <br /> S(r¢¢[Number Street Name <br /> CITY $ E ZIP <br /> uc� 3QG <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (- - 34 e 14 23003 <br /> 11 PHDNE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) co <br /> O I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ <br /> N CHECK IT BILLING ADDRESS <br /> BUSINESS NAME CCCJJI V� \ 1 ` PHONE# ExT' <br /> HOME Or MAILING ADDRESS FAX# <br /> ( � — d ( ) <br /> CITY (l✓ GC K G q5 3 eta STATE ZIP <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 and FEDERAL laws. <br /> /- <br /> APPLICANT'S SIGNATURE: t - f, V DATE: �} ha <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ttt7777 <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 environmental/site assessment! formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It Is providA��BL <br /> my representative. NT <br /> TYPE OF SERVICE REQUESTED: FD <br /> COMMENTS: AMP <br /> ciw r1w SMJOA <br /> �9 218 <br /> NFq I C N&f c rAry� <br /> T <br /> ACCEPTED BY: (MG VU EMPLOYEE#: DATE: 1 ,� <br /> ASSIGNED TO: Cl/1. 1 EMPLOYEE DATE: 3l]9 <br /> r j0 <br /> Date Service Completed (if already completed): SERVICE CODE: ��) P/E: 110 Jn7 <br /> Fee Amount: Amount Paid /6'2 vD Payment Date <br /> Payment Type 4-y Invoice# Chdck# ?� Recei✓ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />