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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 /> N&,1114, <br /> ,tA rG /� �J_ //� •T CHECK If BILLING ADDRESS <br /> FACILITY NAME /1k/�`{�k,(/ �ylrApp <br /> 1 <br /> 3?l JET? SS 5 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Werent from Site Address) <br /> 201 Street Number Street Name <br /> CITY ( — GaTATE ZIP � O <br /> PHONE#11 ExT• APN# LAND USE APPLICATION# <br /> lc5) o -v217A -, to �v <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> Pc F4�il�h -( �� L CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> t. �• �O <br /> HOMEO MAILING ADDR F <br /> ZOO it✓.- �rc # <br /> ) <br /> CITY C�Tv v �� CA STATE ,�/dIP <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.Y, DATE: ' L—�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER THER AUTHORIZED AGENT IIOICGT <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: iq <br /> ft� Aft <br /> � mil I�'► �A""�O 418 <br /> ACCEPTED BY: EMPLOYEE#: DATE: �yiT�RO"MFC (i"� <br /> oZ At <br /> ASSIGNED TO: EMPLOYEE#: DATE: -"R)-4,j "T <br /> Date Service Completed (if already completed): SERVICE CODE: v P I E: 7� <br /> Fee Amount: Amount Pa' 60 6-01 Payment Date 1 <br /> Payment Type Cy Invoice# Check# L) cis Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />