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SAN JOAQ COUNTY ENVIRONMENTAL HEALTH _ .RARTMENT <br /> SERVICE REQUEST <br /> ype of Business or Property FACILITY ID# SERVICE REQUEST <br /> W#2EXT. <br /> ON s °o;/4 526o� I93S <br /> OPERATOR <br /> /D � Z CHECKif BILLING ADDRESS <br /> ME /�Q 7L G--. <br /> O S <br /> ESS .�/�5-_ /GI r GIT/ qtr( 14V e <br /> g 53oL�fula Q, szo <br /> Street Number Dlrection Street Name GIN ZI Code <br /> AILING ADDRESS (If Different from Site Address) / r <br /> Street Number Street Name <br /> f STATE t Zip r <br /> Exr. APN# LAND USE APPLICATION# <br /> if/ - 73 <br /> E%T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEr PHONE# EXT. <br /> -FZ <br /> HOME or MAILING ADDRESS FAX# <br /> 2/95;- /Yuckf Avg ( ) <br /> CITY fo�tkfo� / STATE ZIP �7-5�O <br /> el <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 /> APPLICANT'S SIGNATURE: , &W� t�� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 11THERU 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 environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS projq me or <br /> my representative. 'i *, <br /> TYPE OF SERVICE REQUESTED: �V <br /> COMMENTS: <br /> �� yER O <br /> AgTM11N <br /> ACCEPTEBY: / EMPLOYEE#: / DATE: <br /> ASSIGNED TO: /v LZ EMPLOYEE#: - (J� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Ob� PIE: OaR <br /> 1 <br /> Fee Amount: Amount Paid ,3o D� Payment Date `7/o//�— <br /> Payment Type Invoice# Check# Received By: a/ <br /> EHD 48-02-025 <br /> 07/17/08 SR FORM(Golden Rod) <br />