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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> fA o� � 10 � k OD130 �q <br /> OWNED / OPERATOR �Q / CHECK if BILLING ADDRESSE] <br /> D 7ZG0 o P <br /> FACILITY NAME e0c <br /> leo �* 06 6 <br /> SITE ADDRESS ` / 4ra, , 1//49 e q 3 '7 07 <br /> 050 50 Street Number Direction I Street Name xy Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( `/Z5) 922 4?7c <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> oaqvieP � ( 9/47 ) CYk 9 - F12 <br /> HOME or MAILING ADDk SS FAX # <br /> L? �^ ayryWir 01S ( 916 ) � 16 96 61 <br /> CITY STATE iy4 ZIP 9!57643 <br /> y ,� n C/`f ENT <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent ► � 6VED <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this <br /> activity will be billed to me or my business as identified on this form . N {{ <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN4R)A& UIN 5 2 � 2 � <br /> COUNTY Ordinance Codes, Standards , STATE and FEDERAL laws . SAN JOAQUIN COUNTENVIRONMENTAL Y <br /> APPLICANT'S SIGNATUR P. DATE : <br /> 1Z - � Z / HEALTH D PART NTi <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT � � /�.� 4S <br /> If APPLICANT IS 0 e BILLING PARTY, proof of authorization to Sign IS required Title <br /> AUTHORIZATION TO REL SE 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 /> — ----to-The' AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : 44 :1 )V4A <br /> COMMENTS : n U <br /> II <br /> ACCEPTED BY : EMPLOYEE # : DATE : � I <br /> ASSIGNED TO : V EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check # L 'L Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br /> it <br />