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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 /> CHECK if BILLING ADDRESS <br /> LcL�1 ` ,61 <br /> FACILITY NAME <br /> E —1 <br /> SITE ADDRESS /� 1 �S • 'LC(I✓f S 1 1 �I l�✓ 1 L C 5^✓✓ '7— <br /> Street Number I Direction Street Name City Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) zI 86 -- <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> 00.5' fy.IGi <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> L' 12 i L `1� CHECK if BILLING ADDRESS BUSINESS NAME � �l� PHONE EXT. <br /> 6 # <br /> ( (� o <br /> HOME or MAILING ADDRESSFAx# <br /> ( ) <br /> CITYf /� G 5 STATE rn ZIP y <br /> BILLING ACKNOWLEDGEMENT: I, the Jundersigned 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 FEDERA laws.11 <br /> APPLICANT'S SIGNATURE: DATE: 1 <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 /> 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: S T SIT <br /> COMMENTS: Alo'/ <br /> V 2014 <br /> SAN 1Y <br /> JOA QWN Cp <br /> Ulyry <br /> "C��H t),,,,Tl,L <br /> ACCEPTED BY: g4 _ EMPLOYEE#: DATE: /I 11-711 L/ <br /> ASSIGNED TO: /- 10a411 EMPLOYEE#: DATE: <br /> Date Service Completed (if already c pleted): SERVICE CODE: ct C/ PIE: 230 <br /> Fee Amount: 3�0 Amount Pai 39� �� Payment Date �7 /T <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />