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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oo go + <br /> OWNER/OPERATOR (r <br /> CHECK If BILLING ADDRESS <br /> v � <br /> FACILITY NAME a <br /> SITE ADDRESS F 61 CjZv2 <br /> Street Number Direction Street Name Ci Zin Code <br /> HOME Ori tMAIILING Lay <br /> ` 1-(if Different from Site Address) <br /> rt`, 1 ay JAm Q A Street Number Street Name <br /> CITY STATE ZIP <br /> o c w o Y1 Cbz e�5 ZC �1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> K!1 T.t� 1 �1 1 J 0 A(A �l ,y) Y�. C Crt C t G CHECK if BILLING ADDRESS <br /> BUSINESS NAME V rt 1 v� l` l4 V T �(� PHONE# EXT. <br /> fU 1 hk W 2-,',1) �k- 3 3 ti l <br /> HOME or MAILING ADDRESS FAX# <br /> 3 q Q t(d, Y'),'t o k% C�Y S I ( ) <br /> CITY , STATE 01N ZIP qc� Z� <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. <br /> APPLICANT'S SIGNATURE: c�_ DATE:Tf I <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 kis provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED, r CI �C <br /> COMMENTS: -14* a <br /> lJN tIIL l� J�itf lJ(�1jy j1/V1�✓ s-1 q%4?'� ®,9 <br /> y�4Th�Ep,RIV�4��Y <br /> TMF <br /> ACCEPTED BY: 1 r\v+ EMPLOYEE#: DATE: <br /> ASSIGNED TO: A Cevle EMPLOYEE#: DATE:1—2 Z.✓✓✓�I <br /> Date Service Completed (if already completed): SERVICE CODE: OU ` PIE: <br /> Fee Amount: IrV 0 Amount Pai / �2, b Payment Date Z� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />