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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#:::] �fSERVICEaREQUEST#r ^ <br /> ✓, O 2'VJ <br /> OWNER IOPERATOR ()- � / J /• <br /> •---rte���,�� �� Nr� l99 C� LS,�_CHECK If BILLING ADDRESS <br /> FACILITY NAME--- - <br /> ITE AADDRRESS <br /> J Street Number I Direction Stree[Name CI Zip Code <br /> !4 Or AILING ORES f Different fr Sitg.gaares '.�1¢ <br /> �,l I-Sp �'�-.A `l Street Number Street Name <br /> CITY LL �.' 1 Ulf �Q SJJ1T ZIP <br /> PWHONE V` ` l— ExT� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � �I <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMC, J S� ���1 .sl W, � �"� <br /> OME Qr�AIS1yG ADD[2ESS �t ��/ %# ^ <br /> CITY II r�O)°4 1 ,} STATE ZIPp <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/orCt SpeCIrc ENVIRONMENTAL HEALTH DEPARTMENT hourly Chargee aSSOCIDted with this project or <br /> activity will be billed to me or usin s e Zritified on this form. <br /> I also certify that I have prep red t s a plica• an at,the work to be performed will be done in acco ance with all SAN JonnulN <br /> COUNTY Ordinance Codes,Ste and , A ED E Is <br /> APPLICANT'S SIGNATURE: 1A DATE: <br /> PROPERTY I BUSINESS OWNER❑ ERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT i5 not the BILLING PARTY,Proof of auth r ation to sign is required Tilte <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it Is proy ed to me or <br /> my representative. A. <br /> TYPE OF SERVICE REQUESTED: NQ,v.I h P c7 oyn a4c EC <br /> COMMENTS: D <br /> jt/L 12 20 <br /> �tJVIRO UIN COU <br /> PO L�I q V t ! C D Nv C �' V ! FIt TH DEPAR M� Ty <br /> '7 � T <br /> ACCEPTED BY: I An� EMPLOYEE#: DATE: l h <br /> ASSIGNED TO: J 1%�'� �. EMPLOYEE#: DATE: �I <br /> Date Service Completed (if already Completed): SERVICE CODE: S�3 PIE. ^�O' <br /> Fee Amount: LL�� �• Amount Pa i OE <br /> OT Payment Date '7 z✓ <br /> Payment Type W Invoice# Check# L/'6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />