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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OD u 3KD67 ,Y <br /> WNER/ PERATOR <br /> - Q . 1 CHECK If BILLING ADDRESS <br /> A ILI NAME /y (�^ <br /> SITEADDRESS l- nu <br /> q r +l/,�// Yp\ <br /> O Street Number Direction Q Street NaMe v I 1 ZIP Cotle <br /> HOME Or MAILrI,N10 ADDRESS (If DBren <br /> f t fr my a Address) <br /> J lt.•l Street Number Street Name <br /> TYQckfna CA C 7(9,5 STATE ZIP <br /> PHONE#t _ (� tJ(i APN# LAND USE APPLICATION# <br /> p4T <br /> PHONE#Z E"T BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECIUESTO I CHECK If BILLING ADDRESS <br /> BUSINESS NAM PHONE <br /> C.te a a 0 IG - S <br /> HOME or MAILING ADDRESS AV FAX# <br /> I ) <br /> CITY 5 to C k tan, <br /> 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 /> also certify that I have prepared this application gnd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa STATE a d DERAL laws. <br /> 'APPLICANT'S SIGNATURE: fi DATE: O 3 t e / �— <br /> PROPERTY I 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 info% ation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided tnq <br /> my representative. ee♦r <br /> r ,IrI� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> r U <br /> F����P��� 'J' <br /> UG �l1 �� �� Z I r nr <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: 5-_ _ <br /> ASSIGNED TO: EMPLOYEE#: DATE: j <br /> Date Service Completed ' already completed): / SERVICE CODE: O ' PIE: U 3 <br /> Fee Amount: / t!' Amount Paid' !J 9 U Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> OE7 D7/088 Z-Ozs , 1 I(�0,rUty SR M(Golden Rod) <br />