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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 /> X /C v�_� ,/�W� �G CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> -F -SITE ADDRESS �/�� //� �f7/a,t/T��� 95337 <br /> 2 _7 �;? fre <br /> S ;t Idmb Direction Street Name Ci Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) v� <br /> 2 Z y Street Number Street Name <br /> CITY STATE ZIP <br /> 95 .337 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> hREQUESTORI V� CHECK If BILLING ADDRESS <br /> W IF(' ,1r''y AVJ <br /> BUSINESS NAME PHONE# EXT. <br /> y S I 33 <br /> H ME or MAILING ADDRESS n V� FAX# <br /> / rk <br /> P ( ) <br /> CITY STATE ZIP //IG-3 ►;? <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: ���> �JGz 'l' DATE: !i/- 7. L <br /> E✓ am/J <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑� OTHER AUTHORIZED AGENT ❑ /�/r'S/r/P. <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 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 t0 me Or <br /> my representative. A <br /> 1A b <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 0 <br /> Chan e DwaershiP yRQ />2pf9 <br /> �pq FNT 4iy <br /> Rp �4� <br /> ACCEPTED BY: l/l/1 o ro c EMPLOYEE#: C Q� DATE: J <br /> ASSIGNED TO: �J EMPLOYEE#: U ?7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f i P/E: 1�GI <br /> Fee Amount: �(� Amount Pai077iI <br /> /�� OZ) Payment Date <br /> Payment Type Invoice# Check# Re ived By: <br /> 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />