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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICEREQUEST # <br /> 02,0010 <br /> OWNER / OPERATOR I <br /> ULV <br /> ( � ( ew � 1 J 16 j� CHECK if BILLING ADDRESS <br /> FACILITY NAME A t O n rt IV 4v� E dv ✓� .f, � oVV vv "� <br /> SITE ADDRESS S� 4 , \ A �`-' `�—� <br /> Street Number D rection Street Name city ZIv 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 /> (� 0 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR * � 1 � / <br /> CHECK If BILLING ADORE <br /> BUSINESS NAME (2 _ W 1 t � 0 I ' JC P NE # / _ _ g' OT' <br /> HOME Or MAILING ADDRESS �o D OK � ZL q FAX # <br /> CITY LI&^ F � � CA� 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 . / n <br /> APPLICANT' S SIGNATURE : � C DATE * © ����r �"� <br /> PROPERTY / 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 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. r� Dn p <br /> TYPE OF SERVICE REQUESTED : C ' VII N <br /> z I� cp <br /> COMMENTS: _ / „ �GL ��2_P� �CQ <br /> ViZEI <br /> (1 SAN ,1 2 <br /> EN �gQUIN c <br /> HEALTH pEPARTMENT <br /> ACCEPTED BY : /� � v EMPLOYEE M. DATE : p2 11 <br /> ASSIGNED TO : , V / r 4 / / t� EMPLOYEE ,#: DATE: <br /> L t <br /> Date Service Completed (if already completed) : SERVICE CODE: f ��Z9� PI Eje <br /> Fee Amount: 7 �� Amount Paid O� Payment Date ;2.//, <br /> Y Payment Type ' �r Invoice # Check # 3� D4J- Received By : <br /> EHD 4 &02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />