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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � �� <br /> SERVICE REQUEST <br /> Type of Business or Property/ FACILITY ID# SERVICE REQUFST <br /> OWNER/OPERATORn <br /> dot <br /> �l CHECK If BILLING ADDRESS <br /> (� <br /> FACILITY NAME ��9zt' )�_ p � <br /> SITE ADDRESS 7 60 1J) l,�C-5 n S-le-,w131 -'mac W n 95�(a <br /> Street Number Direction Street Name city Zip Code <br /> HOME orMAILING <br /> /ADDRESS If Different from, iit'ee Address) ^ <br /> 51_) (�I��/7 �(//�- (,I7 Street Number ctq Street Name �5-3 -7 7 <br /> CITY a STATE ZIP <br /> PHONE#1 /�L E'R. APN# LAND USE APPLICATION# <br /> ( � > 97q IQ <br /> 60 o��oyo <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> O <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME C`,/ / _ I„ P�c 1) �7 w / 2 L� EXT. <br /> 1 /j' i't0'Iticell / <br /> HOME or MAILING ADDRESS r� `' /T�� J��� FAX# ) <br /> CITY / y�' / �J 1(75\(J�l � b STATE C ZIP � 317-7 <br /> BILLING✓AC OWLEDGEMENT: 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, 1A�FEaws. <br /> APPLICANT'S SIGNATURE: DATE: l 3 ) . I� <br /> PROPERTY/BUSINESS OWNER E]"' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tir(c <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 ��,��,m``````a-��-tion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it IS proOr <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: "C l L_0 I J bt Z41 <br /> COMMENTS: <br /> 44/0 <br /> V716C hG OI C1 e- 0-F o 1.i/'L.(l� ryoF gRFNONry <br /> T4f <br /> Hr <br /> ACCEPTED BY: `=� ( � EMPLOYEE#: DATE: C; <br /> CA <br /> ASSIGNED TO: — I l(VL t� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L PIE: ) �;Z <br /> Fee Amount: I �� Amount Paid/'�/ U U Payment Date <br /> Payment Type l�� Invoice# Check# 9 32� Received By: i. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �R�u521�i I <br />