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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERV CE REQUEST# <br /> c) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �c) <br /> SITE ADDRESS �L S— G <br /> r� GT u `RJv� <br /> v Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> CA <br /> Street Number Street Name <br /> CI-V\O Q STATE ZIP /^ S-3 5 <br /> PHONE#1 r EXT. APN# LAND USE APPLICATION# `� <br /> lydto`t) l 7 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �I �v <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �^ ^,_\� PHONE# �� � r ! � �T• <br /> HOME or MAILING ADDRESS FAX# / <br /> CITY (v\,--"A 1`_ $TATE /' ZIP C <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: v,Qi C/t-�" ; DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tirle <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: <br /> L UN 19 2 9 <br /> YLC) ma4 (:D1� SAN J <br /> H FNVCOU <br /> lt <br /> v �LTHOEpgR � 7y <br /> ACCEPTED BY: EMPLOYEE#: / DATE: WON <br /> ASSIGNED TO: EMPLOYEE#: V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1# 3 lPY E: / I <br /> iL <br /> Fee Amount: Amount Pa Payment Date Q <br /> Payment Type �� Invoice# Check# J-2Z Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />