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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 � ✓'6 <br /> glAs G/ DD 5-:�Cj l 3 <br /> OWNER OPERATOR _ �� /+��// �� <br /> C r \ /o CHECK 1f BILLING <br /> FACILITY NAME � ) /� r <br /> SITE ADDRESS / /' / <br /> Ell e6l <br /> 3treetNumber /Dirirectlon StreatName Zip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) .2-2— (,[�^.f�/�G(� <br /> op <br /> 212- 3GoStreet Number sweet Name <br /> CITY Q ,��� f-000JZ STATE - ZIP 5 <br /> PHONE#1 EAT• APN# LAND USE AP PLICATION# <br /> (Zero %3;7- 6`3 7 5k I 139- o —08 <br /> PHONE92 E.. BOS DISTRICT LocaT�Ory CDDe <br /> 1 2•``II �'�O 7 s � 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r, - <br /> ;�D � � CHECKif BILLING ADDRESS <br /> BUSINESS NAME /` /V` ' PHONE# t Ev. <br /> N <br /> HOME Of MAILING ADDRESS6o �� (2FAx# ) <br /> CITY O,01 STATE ZIP ] / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized Gagent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application&nd that the work t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT F E L I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPE ORDI 'I MANA ER ❑ OTHER AUTHORIZED AGE <br /> If APPLICANT of the BILL GPARTY oofof ithorization to sign is required TNIe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. '�/n� f <br /> TYPE OF SERVICE REQUESTED: LC S fi Y�-�Ad C1 V r4-(, RE <br /> COMMENTS: <br /> A Ply 1 � 2008 <br /> 'SAN NORONINOOUNTY <br /> HEALTH DE AR�Nr <br /> APPROVED BY: L,1 U, El k2 J�� E1d PLOYEE#: 32 DATE: <br /> ASSIGNED TO: I EMPLOYEE#: i DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( 3 PIE: 30 SS <br /> Fee Amount: # ;;t I <br /> Amount Paid 'a9 Payment Date Lk O' 0 Q <br /> Payment Type Invoice# Check# 3 12 S Received By: N <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 0-5-02 <br />