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SAN JOAQUIS41OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> OWNER/OPERATOR D O O Q O / <br /> TOwE2 <br /> FACILITY NAME <br /> CHECK If BILLING ADDRESS <br /> SITE ADDRESS F7& <br /> iti� �rr / <br /> Street //IVYsr� <br /> Number Direction �G�Glx 4,Z 0 ' j� 2_1 '7 <br /> HOME or MAILING ADDRESS (If Different from Site Address) ---Name CI <br /> zl cede <br /> CITY Street Number <br /> yy// Street Name <br /> STATE ZIP <br /> PHONE#1 Ems, APN C <br /> LAND USEAPPLICATION# <br /> L <br /> PHONE#2 <br /> /i / EXT. <br /> (C//6 ) y 6 7V//� BO$DISTRICT LOCATI`CODE <br /> REgUESTOR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> V� {/ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME y�',,e ,l C <br /> U v� G/'I_Q—[i' O PHONE# <br /> HOME or MAIUNG ADDRESS ,,/ J C.O T r O �. ,( <br /> CITY l v �' C/�s�.L,µMp�+ ( # ) fv I <br /> STATE /7n ZIP Q r-p 2 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized Uagent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with thi <br /> or activity will be billed to me or my business as identified on this form. s project <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 Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �./� �— <br /> � DATE: <br /> PROPERTY/BUSINESS OWNER — <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is n a i the BILLING PARTY Proof Of authoriZOn 011 to sign is required <br /> Title <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. <br /> TYPE OF SERVICE REQUESTED; <br /> COMMENTS: w^a�' RECEIVED <br /> FEB 2 6 2008 <br /> SAN JOAQUIN COUNTY <br /> NVIHEAL HHDE ARTMENr <br /> ACCEPTED BY: <br /> EMPLOYEE#: 'J DATE:ASSIGNED TO. J O� <br /> EMPLOYEE#: DATE: <br /> Date Service Co eled (if already completed): ' �� <br /> SERVICE CODE; �i�1) l E: <br /> Fee Amount: 9 Amount Paid Q- -- .]] b6 � <br /> Payment Type / vv Payment Date a� <br /> Invoice# Check# <br /> eceived By; <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br /> SR FORM(Golden Rod) <br />