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SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR l4ao„ CHECK if BILLING ADDRESS <br /> tiv d J r N �n�ti � � �� <br /> FACILITY NAME T\_ (� >� y(h f CC � �� t/� <br /> SITE ADDRESS �."�7 +/�'��FPII luo p, �Mc \L� l <br /> Street Number I Direction V V I`Street Name ItyZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /i 1 <br /> AY �� n /1 O CHECK if BILLING ADDRESS <br /> 40 <br /> BUSINESS NAME Th!'/��l Pa I rv-` 1 UUs (-Ia) YIA PHONE# EXT,tl 1 <br /> HOME or MAILING ADDRESS ` F FAX#Al L <br /> Vk � ( ) <br /> CITY r O' STATE (qt ZIP (��2'A 0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, oper'at`or 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 Codes, Standards, STA E and FED AL laws. <br /> APPLICANT'S SIGNATURE: DATE: I n 1"I <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER Er 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, 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 asse ment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It lme or <br /> my representative. it, <br /> TYPE OF SERVICE REQUESTED: �' y„ c i l �® <br /> COMMENTS: / 20i? <br /> SANJOAQU/N CO <br /> kF/VVv( <br /> C 1 Ci 11 Cd-� �� 0EJ % Z!i�� NEp TN EPgR ME TY <br /> 11 NT <br /> ACCEPTED BY: e— EMPLOYEE#: DATE:3. / / _ 7 <br /> ASSIGNED TO: l EMPLOYEE#: DATE: 7- / <br /> Date Service Completed If already completed): SERVICE CODE: 0 , TPI E: I FeeAmount: JCai Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />