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SAN JOAQQCOUNTY ENVIRONMENTAL HEALTH9PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#' <br /> a F)+ ego »C?C� 2)gO6 Wy 5 <br /> O NER f OPERATOR <br /> //�``'AI0 <br /> lecl , �� �� <br /> CHECK If BILLING-ADDRESS <br /> FACILITY Nf:12� <br /> V) <br /> SITE ADDRESSX05" {t✓ �oS 4"I e �J 42 95 331- <br /> o Y.-5 P ttis 13-a <br /> Street Numb r Direction Street Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> # Street Number Street Name <br /> CITY O SQ TE ZIP 6 <br /> PHONL#1 EXT. APN# LAND UsE APPLICATION# <br /> 3 3 a5 1-7 VQ 6 <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ( <br /> C/ONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ie /i. / f (qCHECK if BILLING ADDRESS <br /> Po <br /> � ^� S 7DNE# -+�BUSINESSN I= Y/t t! �� �e PHEXT. <br /> ' r <br /> HOME or MAILING ADDRESS �f �t I FAX# <br /> CITY TATE 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 Cotes, Standards, TATE and F ERAL laws. <br /> APPLICANT'S SIG RIATURE: � lj 'No SJe ✓ HATE: 03 �2z 1 zor b <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT isn t 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 environmentallsite assessment information <br /> to 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: l V <br /> IE <br /> SAN JMAR2�?01� o <br /> q <br /> HEAL ti00�Nrq� TY <br /> ACCEPTED BY: EMPLOYEE DATE: .� <br /> ASSIGNED TO: �— EMPLOYEE M DATE. 3_ ! ,M, <br /> Date Service Completed (if already completed): SERVICE CODE: 1� P/E:O`! 0 6a <br /> Fee Amount: Amount Pa€&` Payment Date <br /> — <br /> Payment Type � �y Invoice# Check# Received By-dlN <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />