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SAN JOAQUCOUNTY ENVIRONMENTAL HEALTH DOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DQ0060 <br /> OWNER/OPERATOR `� /,� <br /> • \ /La o�` c- CHECK if BILLING ADDRESS <br /> ,--Q_ <br /> FACILITY NAME .r v f1� —V rA7t J 0 A <br /> SITE ADDRESS ) \ � �1�c <br /> Street Number Direction Street Name city Zip Code <br /> -[-- <br /> HOME or MAILING ADDRESS If Different from Site Address 7 <br /> ( , q o (- -Tw <br /> Street Number Street Name <br /> CITY r f ra I / STATE ^ ZIP <br /> PHONE 1#11 ('( EXT. APN# LAND USE APP'PiLICATION# a J O <br /> (eiW -1S3 —(C8,q <br /> PHONE#T <br /> EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> -TrvG a+�o o <br /> HOME or MAILING ADDRESS ^�juo FAX# <br /> -I Tw-h Ci `e5 c ) <br /> CITY STATE C AT ZIP e-1,5(0 Z 4 <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 /> I 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: D Z � "/t <br /> PROPERTY I BUSINESS OWNER e I 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JAN t 4 209 <br /> I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C ( �_ t EMPLOYEE#: S175 <br /> DATE: <br /> ASSIGNED TO: r,/���•O�► EMPLOYEE#: CIQ3 DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: ('G0/nI PIE: <br /> Fee Amount: 1521" Amount Paid t52,C)Z) Payment Date 1Z� l t� <br /> Payment Type lIt debt Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />