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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/OPERA, CIR ' / <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �- <br /> �-S <br /> SITE ADDRES�,',-,,, it vC Ll!•� %fid, �� S 35? <br /> Street Number Direction Street Name / city Zip Code <br /> HOME for MAILING ADDRESS (If Different from Sitie Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 _ ExT• APN# LAND USE APPLICATION# <br /> (7.24 3Z/ - (r, /i 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> C[EUSINEss <br /> EQUESTOR <br /> CHECK If BILLING ADDRES <br /> NAME PHONE# EXT, <br /> IJIF <br /> OME or MAILING ADDRESS FAX III <br /> ITY J/JA �L C STATE �� ZIP ILLING 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: l/��✓' � DATE: � r J <br /> PROPERTY/BUSINESS OWNER Q OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY.Proof of authorization to sign is require[/ 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 it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Py <br /> R CIrEr) <br /> MAY U 6 6.3 <br /> Sq EJOAQU/N <br /> ACCEPTED BY. EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid �� Payment DaW4-0- aote <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />