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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 Yom, <br /> CHECK If BILLING ADDRESS <br /> - D r,,15 m <br /> FACILITY NAME "Df-C-0,VvN 1 C f C f-e� I` i Qr— <br /> SITE ADDRESS 1 I k v ``LW'vri/l LJ`Lt� `� cok\ <br /> treet Number DErectlon Street Name CItxZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7 (Y7 L t- c+ f,, <br /> Gam( �V4 1 cJ f Street Number Street Name <br /> CITY / '�„ �� { _V-k STATE CA <br /> ZIP 7�-2 10 <br /> PHONE#1 o EXT. APN# LAND UsE APPLICATION# <br /> (?.al) 06 <br /> PHONE#2 EXT. 1305 DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR ((���� �f _ <br /> `v t�y1 ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME V�c 2 PHONE# EXT. <br /> e a ��e�w 4 <br /> HOME Or MAILING ADDRESS S114 <br /> {"# ) <br /> CITY (�,�L �� STATE C(A ZIP S i <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: DATE: ( �� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the MILLING 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 <br /> TYPE OF SERVICE REQUESTED: (� C <br /> COMMENTS: MA y O i 7 <br /> PJ 42 <br /> LT1iRONM NtAL <br /> . DEA'4RTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: t EMPLOYEE#: DATE: '2 -0 <br /> I, "7 <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: 3��' Amount Paid 'S Payment Date <br /> Payment Type LS�`� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />