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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> 05� G0A41f6rINX A3r3V' Sdi <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME /^Q /� 1^ � � � � �^ <br /> SITE ADDRESS336 c Sovjjs! �} / / i2 ® �2 � S oG/ ;oZ <br /> � 5F; o3 <br /> Street Number Direction (/( Street Name Cit Zi Code <br /> HOME Or MAILIN,C ADDIj ( If Different from Rita nrirlrcccl r /� <br /> Street Number Stree Name <br /> CITY O � STATE ZIP <br /> PHONE #1 EXT APN # LAND USE APPLICATION # <br /> ( ZVI) X.5 2 - D/6o <br /> PHONE #2 E)c . BOS DISTRICTLOCATION CODE <br /> ( • <br /> 1 71 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � 7 � ,/� ^ A CHECK if BILLING ADDRESS ❑ <br /> BUSINESS NAME �/ ^� , L PH'LONE # � o � EXT, <br /> V ^ � C� <br /> HOME or MAILING ADDRESS I FAX # <br /> CITY O 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 /> f <br /> APPLICANT ' S SIGNATURE : r DATE : ,r /� Z <br /> PROPERTY / BUSINESS OWNER,B OPERATOR / MANAGER 13 OTHER AUTHORIZED AGENT ❑ / ✓ Ci ` <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 /> to the SAN 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 /> _ 1 _ , I <br /> TYPE OF SERVICE REQUESTED : (�� ��?Ov �� L � ®ye5g <br /> L r , <br /> COMMENTS : <br /> AI <br /> S NVI 2OUlN t:0(1NTY <br /> HE,�LTH p�j") L <br /> ACCEPTED BY : � " V\ f EMPLOYEE # : DATE : /� <br /> ASSIGNED TO : / EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : �� ( /. — /� PIE :4;)1e 00 <br /> Fee Amount : OlJ Amount PaidPayment Date + 11 T <br /> Payment Type Invoice # Cgec 12 6) ? Received By : <br /> EHD 48-02-025 SR FORM (Golde <br /> 07/ 17/08 <br />