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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFr-ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OVVN'SP!OPERATOR <br /> C(.Lr l CHECK if BILLING ADDRES <br /> (- <br /> S <br /> FACILITY NAI'AE / <br /> SITE ADDRESS S <br /> S[reetNumber Dir t'n <br /> HoMF Or MAILku ADDRESS (If Different from Site Address) <br /> - ?/-/— CStreet Number -� Street Name _ <br /> CITY ZO STATE. ZIP <br /> �LY�N S�l/U <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 1-15- oy -o9 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/' SERVICE REQU :STOR <br /> REQUESTOR <br /> > CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE ExT. <br /> E- L pa y qy&-o Z <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouivTY Ordinance Codes, Standards,STATE and F ERAL laws. <br /> AP,*LICANT'S SIGNATURE: DATE: ✓ v <br /> PROPERTY/BUSINESS OWNER❑ HOP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 4� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AU rHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 informatin` <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to ma. <br /> my representative. ^Ir� <br /> TYPE OF SERVICE REQUESTED: - j "►�t,�� <br /> � 1 Ct✓ L? � � VFX <br /> COMMENTS: T�vc I ) 1 1 m PovW► 4 t IC 14-Ck- I u'q4 �tiw� y6P12016 <br /> `� 01r1--� 0/11 &N Zk- 06' AfwI r T����� �rq�NTY <br /> MST <br /> ACCEPTED BY: EMPLOYEE#: _ DATE: C5.Zo . I <br /> ASSIGNED TO: � to�nh EMPLOYEE#: -- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 I E:f f 1`I <br /> Fee Amcont: '— Amount Pa 3 l o v Payment Date s V <br /> Payment Type �� Invoice# Check# Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />