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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> LFACILITY <br /> usiness or Property FACILITY ID# SERVICE REQUEST# <br /> c T Q 0_�� <br /> OPERATOR <br /> CHECK if BILLING ADDRESS <br /> ME SS C-_ OC <br /> saeel Number Direction /" / / Street Name cit, ZIo Code <br /> HOME or MAILING^A-i Different fro�mL Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lam ' C.a- X52--f' <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( I 'le y-3 2,1— 0 , 1 1-1� - -Z(„(D -- � Z <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> I I CX5I O) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex1. <br /> HOME or MAILING ADDRESS FAX It <br /> CITY STATE 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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard ST nd of aws. <br /> APPLICANT'S SIGNATURE: — DATE: k 2— 12— <br /> PROPERTY I <br /> —PROPERTY/BUSINESS OWNEP;ff OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ .5e .--y <br /> If APPLICANT IS not the BILLING PARTY proof of authorization t0 sign is required Tifle ' <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Frzld a" RE <br /> COMMENTS: <br /> DEC 3 0 201 <br /> 'A'VHOI �M COU 1Y <br /> ,,tt H"t-rH 1)uPAR, <br /> ACCEPTED BY: r\/pri'�^ _ EMPLOYEE#: DATE: <br /> ASSIGNED TO: xr' 11U/Z�r EMPLOYEE#: DATE: T <br /> Date Service Completed (i (ready completed): SERVICE CODE: S�ZI PIE: 160 <br /> Fee Amount: Amount Pal ' Pa ment Date !2 <br /> Y <br /> Payment Type Invoice# Check# C7r! � Receiv6d By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />