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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � �r��rtic SPMIC <br /> OWNER/OPERATOR f `1 <br /> �A'�jtY � 1�OT ��Q \lt 1 � t_M w_ ) CKIfBILLINGADDRESS <br /> FACILITY NAME Y- 1�CR /`tfV <br /> a &Ar ,4c.c�r� NVT <br /> SITE:jt5plEs.0 <br /> Street Number I Direction Street Name Ci Zi Code <br /> HOMES or MAILING ADDRESS (If Different from Site Address) <br /> if Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT_ APN# LAND USE APPLICATION# <br /> ell S7?- o« Z1?� D ZO t J PA,- I&=z4+ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSIN SFy$ NAMEExT. <br /> � OUT <br /> PHONE# c5� v114 <br /> HOME or MAILING ADDRESS FAX# <br /> 151-7—O 11 l• <br /> CITY A ZIP Q <br /> r F <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 busi&OPERATOR/ <br /> form. <br /> I also certify that I have prepared this ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S <br /> APPLICANT'S SIGNATURE: DATE: 4d <br /> PROPERTY I BUSINESS OWNER❑ —.-•—�TFiEfiAUTHORIZED AGENT <br /> If APPLICANT is not the 81LL1NG 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 asse��y/�yg��[ t1�n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time It ISpTOVrd �r <br /> my representative. pRdddRRR CCCCIEEEEEE VE <br /> TYPE OF SERVICE REQUESTED: t <br /> --Ip 7019- <br /> COMMENTS: <br /> iAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEt IT <br /> ACCEPTED BY: EMPLOYEE#: DATE: / Q <br /> ASSIGNED TO: V EMPLOYEE#: t/V!/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid — Payment Date <br /> Payment Type t Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />