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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ag 2 06 7�, b <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME YI/ <br /> SITE ADDRESS <br /> /N q 7 Street Number I Direction lI _"`S-e�- Street aneTI ZI Catle <br /> HOME or MAILING ADDRESS (If Different from//Site Address) <br /> Street Number /7� 5 eet Name <br /> CITY STAT ZIP ^s <br /> PHONE#tT APN# LAND USE APPLICATION# C/ <br /> ( ?moi L( o9 -? 3 <br /> PHONE#2 aT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PdS <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME1 PHONE# EXT, <br /> HOME or MAILING ADDRESS FAX# <br /> 17 Vv w, a� Ltil ( ;�,A <br /> CITY ,[-,r�Q 1 _ c4 <br /> 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 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: -Z6 :� DATE: <br /> PROPERTY I BUSINESS OWNER[I OPERATOR/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 assessmentinf tion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided[ <br /> my representative. �/ / ` FNj <br /> TYPE OF SERVICE REQUESTED: /U Cly(,"L/� AHI D <br /> COMMENTS: 4 EriOA Cp , <br /> ACCEPTED BY: Cpn rD EMPLOYEE#: DATE: 0 <br /> ASSIGNED TO: of )�/; EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 5 3 PIE: <br /> Fee Amount: J w Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />