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SAN JOAQIQCOUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU�JE"_ST# <br /> C Sp t <br /> D6-7(o I <br /> OVVNERJ O ERATPR tI l �f� CHECK if BILLING ADDLE <br /> FACILITY NAME /� <br /> SITE ADDRESS S� qJ �S <br /> C V�L�Q Lr <br /> d Z Street Numher IIIrectlan Street Name C[ ZiCode <br /> HOME Or MAILING ADDRESS (If Different from S e dress) DOr C r-d-jc+ <br /> S_65 Street Number Street Name <br /> CITY �^,}yt GIi�� STATE ZIP <br /> CA— <br /> PHONE;1 + �ey� EXT' APN# LAND USE APPLICATION# <br /> 2- <br /> PHON #2 EXT. 130S DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4/ <br /> CHECK if BELLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> I <br /> HOME or MAILING ADDRESS FAX# <br /> i 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 /> 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: a v"oli1,1!1 <br /> DATE: <br /> PROPERTY I BUSINESS OWNER❑ PERATOR 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It is provided to me Or <br /> my representative. p PA IVA, <br /> TYPE OF SERVICE REQUESTED: aGI yv f�~i�� <br /> I� COMMENTS: n <br /> NOV 0- i/2 <br /> SAN�0 4l& <br /> AC) <br /> ENV? ON j� lit cro Oo ilv,I v y <br />� R Ak <br /> MENT" <br /> ACCEPTED BY: EMPLOYEE : L� DATE: J Z r <br /> ASSIGNED TO: [ --C EMPLOYEE M DATE: rd 2 <br /> Date Service Completed (if already comp) ed): SERVICE CODE: 0-6 / Pe": <br /> I <br /> r l <br /> Fee Amount: -00 Amount Paid � �e Uv Payment Date S�� I <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />