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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Pr001 2 SRboNZ`iS <br /> OWNER/OPERATOR <br /> _ 5 �u R CHECK If BILLING ADDRESS® <br /> F lury NAME r <br /> G <br /> SITE ADDRESS r� c I r <br /> 8 ,H Str e N bei Direction Street Name SAN 3CIN <br /> UN G ���pbb <br /> HOME Or MAILING ADDRESS (If Different from Site�C t^e Address) <br /> V Street Number Street Name <br /> C TY STATE ZIP <br /> LR Cir <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (bsa 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CED1 TPACTOR SERVICE REQUESTOR <br /> REQUESTOR r1r1��p1p1 <br /> CHECK It BILLING ADDRESS <br /> BUSINESS IFINNAME <br /> �KD D PHONE# Ezr. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY SA,• ` 0 STAT zip y0 (40 <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:. l_T/L/5 6 2E�� � �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. Ip <br /> TYPE OF SERVICE REQUESTED: rvod vt/ItL(64P' M oPCL <br /> COMMENTS: <br /> 00 <br /> O <br /> 6�.R1 <br /> F T <br /> 41 <br /> ACCEPTED BY: EMPLOYEE#: DATE: �1 t„ I r <br /> ASSIGNED TO: Cru (•,II .M EMPLOYEE#: DATE: Gl 19 I Y�/ <br /> Date Service Completed (if already completed):i/ l SERVICE CODE: sC_%?f r PIE: 1co63 <br /> Fee Amount: �'}�,00 Amount Paid> ` �b O� Payment Daae -P- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />