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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE�S7T# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSJ9 U YTO C/�TO•/J 7 5 2- <br /> �y'2 Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY CK Tu..0 STAT., ZIP C/75-on <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20cl) '2 L4 2— t-!/ <br /> PHONE;i2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS L3i� <br /> BUSINESS NAME PHONE# EXT. <br /> G <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 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: DATE: �����Fr <br /> PROPERTY/BUSINESS OWNER OPERATOR ANAGER [IER RUTH D 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 prop ��(yp above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si sst nTOrmation <br /> �.a <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same, I EVome or <br /> my representative. NOV <br /> TYPE OF SERVICE REQUESTED: �o l0 <br /> SAN JOAQUIN COUNTY <br /> COMMENTS: ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: f EMPLOYEE#: 51)-7-6 DATE: <br /> ASSIGNED TO: W1• EMPLOYEE#: f/�/LZj DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: v 6 PIE: D O_5 <br /> Fee Amount: �Z"d D Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />