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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' F�- DO 0 � �lZ007�-7 <br /> OWNER I OPERATOR CHECK If BILLING ADDRES <br /> It <br /> FACILITY NA <br /> L=� � D L— �C-r"T / <br /> SITE ADDRESS _ /� O�L )/&7- A'(�C-, 9 33 b <br /> 1330 Street Number Direction C Street Name CI ZID Code <br /> HOME OM�NGAyVf nt from Site Address) <br /> ()o� ( <br /> (2r Street Number Street Name <br /> CITY 1 020 C,4--STATE /S3 <br /> PHONE#t Exr. APN# LAND USE APPLICATION# <br /> P-69) fo 03 1 �2--2 <br /> PHONE#2 E". BOS DISTRICT LOCATION C DE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Yv G10n1 /� <br /> BUSINESS N PHONE# Ext' <br /> 03 -gel <br /> HOMEOr MAILINGAD <br /> --LYE _ / F(AX# <br /> ? ) <br /> �r / t <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 I have prepared this applica'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TATE d FEDERAL I s. /, <br /> APPLICANT'S SIGNATURE: J // DATE: I I o li 7 <br /> PROPERTY I BUSINESS OWNER PL OP AT IMA GER OTHER AUTHORIZED AGENT ❑ OWf� <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 as It Is available and at the Same time It i&provided to me or <br /> my representative. '�A <br /> TYPE OF SERVICE REQUESTED: 1 �y <br /> COMMENTS: <br /> fi ThDep��COU <br /> ,'Y <br /> EN <br /> ACCEPTED BY: 2,PA tY4 <br /> EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: Q- <br /> DateServiceCompleted (if already completed): SERVICE CODE: p(Q' PIE: l <br /> Fee Amount: �"Jaw Amount Paid j �� Payment Date lb <br /> Payment Type -f Invoice# Check# Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />