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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 <br /> CHECK If BILLING ADDRESS <br /> c a r tc� til T*a ca In . <br /> FACILITY NVE <br /> r P-"C r Lmn D <br /> i <br /> SITE ADDRESS W��` ,(� ( 1'Y t YI l A �,A Y'n A <br /> G Street Number I Direction Street Name citv Zip Code <br /> `HOME or MAILING ADDRESS (If Different from Site Address) <br /> Lk <br /> KC`` J Street Number Street Name <br /> CITY TATE ZIP 4 W <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> & \I�\� C 91i�t CHECK If BILLING ADDRESS <br /> f'nBUSINESS NAME �'� W PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY1 �C`` STA E 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 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. O� <br /> APPLICANT'S SIGNATURE: ��� DATE: t b 1 <br /> PROPERTY/BUSINESS OWNER-;a_ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT A 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 time4 provided to me or <br /> my representative. �YIII <br /> TYPE OF SERVICE REQUESTED: n IIZC � <br /> COMMENTS: ` y <br /> Sft jo 6 ?019 <br /> y�crtioQ�F�o�,y <br /> Chan Y cT p w�-lrsh l p -RTMEryNT <br /> ACCEPTED BY: c C EMPLOYEE#: 22(2 DATE: 7 <br /> ASSIGNED TO: n 1 l ✓� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f n P/E: 1 <br /> Fee Amount: I r--2 (� Amount Paid , /say Payment Date 7 <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> � 1�I232 <br />