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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> F' .tf S v1 i i v\ ZVI C • <br /> SITE ADDRESS ( 162 <br /> Q � � 3 <br /> c� � � Oln l�lv+C SSG � � Y2D <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ' 22 `C J��/ A�35tre� Number EJ � C � St eef tRame <br /> CITY ESCOJOA C14 qrP 2O <br /> PHONE #� `l EXT, APN # LAND USE APPLICATION # <br /> dol 99 2 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMES 1 ( PHONE # EXT. <br /> n Ho 1d; 2+AC . 20 zs' <br /> 992 • � <br /> HOME or MAILING ADDRESS FAX # <br /> CITY ESC'J4L- '6fV STATE G14 ZIP 9 S3 Z-O <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 applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE EDERAL laws . <br /> APPLICANT'S SIGNATURE : DATE : Z / JL/� Z41 S <br /> PROPERTY / BUSINESS OWNER El OPERATOR / MANAG 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 thabove <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment infdtj ii n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provid ��� <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : V <br /> COMMENTS : �G` `TOA 2 <br /> g'Eq tv 2 Qui V <br /> lTtio0 gRFT q�N <br /> ACCEPTED BY : EMPLOYEE # : Ct <br /> DATE : <br /> ASSIGNED TO : • • ` JQEMPLOYEE # : DATE : <br /> Date Service Completed (i eady completed) : SERVICE CODE : � ( iJ Q PIE : <br /> a '30 <br /> Fee Amount: Amount Paid , Payment Date f / <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />