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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P-e"- M u ro N �� 5 k cul <br /> OWNER/OPERATOR <br /> r CHECK If BILLING ADDRESS <br /> A C'FACILITY NAME I Y I <br /> 1 � <br /> SITEADDRESS A/ <br /> 1 i 4 Street Number Direction r Street Name CityZf Code <br /> HOME <br /> or MAILING ADDRESS If Different from Site Address) <br /> r ,)- box 49A Street Number Street Name <br /> CITYY 0 TATE ZIP 5 ` <br /> PH NE#1 EXT. APN#;�5 S ' 2-0 4P Z LAND USE APPLICATION# <br /> c i�3 S fog (O <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) ef�) 0 q <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / i CHECK If BILLING ADDRESS <br /> i Edi -If— <br /> PHONE EXT, <br /> ! N E J o� o �4-. 4-2 g7 2 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY I STATE G ZIP 6t15 <br /> BILLING A KNOWLEDGEMENT: 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 ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. -�J <br /> APPLICANT'S SIGNATURES DATE: I <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ry t Q 1��, <br /> If APPLICANT is not the BILLING PAR Y,proof of authorization to sign is required 7'irle J <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 i formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is providt Or <br /> my representative. "'''"'''"llllll,� r <br /> TYPE OF SERVICE REQUESTED: 7:coCk �IQ y\ C*Isc. - <br /> g'SgN✓ ,0 2 O <br /> COMMENTS: <br /> I �Y'CJS y F�� <br /> 2-C( Eg4T�oq� <br /> TMEN <br /> ACCEPTED BY: � i EMPLOYEE#: DATE: f. I O / <br /> ASSIGNED TO: EMPLOYEE#: DATE: !! O <br /> Date Service Completed (if ItIready completed): SERVICE CODE: PIE: <br /> Fee Amount: "1 � Amount Pai v-6 Payment Date 7 l P11 <br /> Payment Type Invoice# Ch k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />