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l <br /> 2,3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#� ILs <br /> �SE6VJC REQUE T# <br /> hiqj��§ <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS � , „�\5e- �v� `cvk--�V-C'S� Fa CJ3.3D <br /> v <br /> '✓'S Street Number Direction W Street Name Ci \ Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> r r Street Number F Street Name <br /> CIT STATE ZIP <br /> �C L"N ecce Ci S 331 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (?0`1) 2'aa -9LoSS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (931)42o --IUU '2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> C-0-'c <br /> '� _ 'c�,e,� <br /> BUSINESS NAME PHONE# EXT. <br /> C,G r \h C-v'\ 209 3,9a-9 t.t 5 <br /> HOME orMAILING ADDRESS FAX# <br /> �iI of` 0�-d.�V� \W`E'T L-C.'V` 7 - ( ) V,I a- <br /> CITY ` A C �oq'- <br /> STATE c� 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 /> 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: <br /> PROPERTY I BUSINESS OWNER lid OARATOR/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 assessor t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is pr D m Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: /�( 1�oti VF <br /> COMMENTS: <br /> JX019 <br /> Ely1 AQUmN <br /> h�Ttip pqR MIJ, �Y <br /> Nr <br /> ACCEPTED BY: �' �( r EMPLOYEE#: f7 ) DATE: <br /> ASSIGNED TO: V 61 � 1 EMPLOYEE#: / DATE: O® <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: J <br /> Fee Amount: Amount Paid Payment Date S / <br /> i <br /> Payment Type ��. Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />