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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pe f" /-1 11 E 9Q <br /> OW ER I OPERATOR ^ CHECK If BILLING ADDRESS <br /> FACILITY NAME l <br /> SITE ADDRESS <br /> i 5 Z 5 Street Number DImetton J SYe Name C 21 Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 56 -L" E L U G11 Il '7 L' Street Number Street Name <br /> CITY <br /> STATE ZIP <br /> / Z <br /> PHONE#1 �U APN# LAND USE APPLICATION# <br /> (iyy) �7, -7 <br /> PHONE#2 E%T. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /1 / CHECK If BILLING ADDRESS <br /> BUSINESS NAME i, (HONE# _IZ 7 / <br /> EXr. <br /> HOME or MAILING ADD SS T FAX# <br /> CITY Tit STAT E ZIP /.. <br /> G J <br /> 'I 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �(;"Z, /:�- 2"/ DATE: 2 ' /7 <br /> PROPERTY/BUSINESS OWNER LM—' OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 Is provided t0 me Or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: 1'r6 <br /> DCOMMENTS: <br /> SPAy <br /> TACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: a Z_ EMPLOYEE#: DATE:Date Service Completed (if already completed): SERVICE CODE: � <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Cheek# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />