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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH utEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business <br /> or Property FACILITY ID# SERVICE REQ/UIE,ST�j# <br /> /L/✓ry' / J�C.1� `"���r IJV �7�i.coo <br /> OWNER/OPERATOR <br /> Gi1/G[� /L_ CHECK If BILLINGADDRESSO <br /> FACILITY NAME/— �`� <br /> SI�T7E�ADDyRES _ <br /> `' Street Number Direction �"' ;�/AStreetName • �� /oG Ci <br /> HOME orMAILINGADDRESS (If Different from Site Addr ss) <br /> r0 l' 0� Street Number Street Name <br /> CIT , Q STATE -pp S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1 PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> j REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUS NESS NAME ! PHONE# EXT, <br /> HOME Or MAILING ADDRESS FAX# <br /> Z� vq G11-i c ) <br /> CITYM v j STATE ZIP QZ—S Z <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 /> also certify that I have prepared this applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE FEDERAL I S. <br /> APPLICANT'S SIGNATURE: DATE: / / <br /> PROPERTY/BUSINESS OWNER❑ OPE / NAGER ❑ OTHER AUTHORIZED AGENT 03 <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 a5 It IS available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> NOV 18 26':5 <br /> SAN JOAOUIN COU TY <br /> ENVIROMENTA <br /> HEALTH DEPARTM NT <br /> ACCEPTED BY:(_� EMPLOYEE#: DATE: <br /> ASSIGNED TO: �10 h sc U t Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ?� P/E: <br /> Fee Amount: f — Amount Paid 7 C - Payment Date l(- <br /> Payment Type Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />