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SAN JOAQLM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> OWNER/OPERATOR I/ CHECK if BILLING ADDRESS <br /> JCnV,� <br /> FACILmNAME A^ Cl�rrQ,Sc. <br /> �uhf� Club 6fv S-Ivv For Clai � <br /> SITE ADORES DI n Code <br /> DDO l� Sheet Number Direction Street Name r <br /> HOME Or MAILING ADDRES (If Different from SIle q/d{lress) {Z„f. O C I r C l e <br /> 7�5 r a !"7S l_Ir� 5[re¢t Number & She¢t Name <br /> STATE <br /> CITU d- <br /> C/�'- ExT. qpN# LAND USE APPLICATION# <br /> PHONE#1 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> t�A&-, L . C,— <br /> EXT. <br /> BUSINESS NAME <br /> � ✓� / <br /> HOME Or MAILING�DD SS /l.• �/ �f/ Fes# O— <br /> �h C I ) <br /> CITYSTATE I ZIP <br /> �.✓1 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE-air F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ��// h <br /> PROPERTY/BUSINESS OWNER W OB RAT R1MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I"Q,l <br /> If APPLICANT is not the BILLING PAR 7Y,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 sari time it is provided to me or <br /> my representative. ��I 1 <br /> TYPE OF SERVICE REQUESTED: ECEIV <br /> COMMENTS: NOv 0,1 ZQ� <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 1 hi '�sL�U�1hG 'o� <br /> ASSIGNED TO: +i ) <br /> . EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: V ! PIE: <br /> V <br /> Fee Amount. ,t' >.. t 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 />