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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNERIOPERATOR -T CHECK If BILLING ADDRESS❑ <br /> C <br /> FACILITY NAME ^i' j�U�/r' " I , <br /> l JL-f l ��,,�}.� r� <br /> SITE ADDRESS S 1 I tK)�r1L ''a y ��O y�I�yI -o <br /> 24 Street Number I Direction 1 f Street Name CI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ',(y4.�-(-A � 'LY <br /> _ Streat Nomber Street Name <br /> CITY STATE, ZIP O <br /> T.9� ��� C-�f4 <br /> PHONE#'I _ EXT. APN# U LAND USE APPLICATION# <br /> qk17`6,1 qu <br /> I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> ( ) 1 a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR "43 G CHECK if BILLING ADDRESS <br /> � Neu ��J <br /> BUSINESS NAME /r , ) PHONE# FXT' <br /> q0 -72Q D <br /> HOME or MAILING ADDRESS FAX# <br /> �r <br /> CITY �A J STATE ZIP Q\ ,Zo z <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 ban FEDERAL laws. f A—/r <br /> APPLICANT'S SIGNATURE: � L��n_ DATE: ` ' 12- 1 I <br /> PROPERTY I BUSINESS OWNER OPERATOR t 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 environmental/site assessmen ' formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is q o me Or <br /> my representative. G,�'eA•VVV��- <br /> -1409 <br /> TYPE OF SERVICE REQUESTED: Foori h 1 <br /> COMMENTS: w\OV t1 \ GOJN <br /> LIc-� vfit� A� <br /> P� <br /> + q <br /> ACCEPTED BY: n�I EMPLOYEE#: DATE: 11-IJ- J-7_ rL _ / <br /> ASSIGNED TO: �i1 I lw e-L/.t EMPLOYEE#: DATE: I I -Zi- <br /> IL 7 <br /> - /' <br /> Date Service Completed (if already completed): SERVICE CODE: /P/E: (� /3 <br /> Fee Amount: ✓ Amount Paid 15 2 Payment Date <br /> Payment Type h Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />