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SAN JOAQUiIv COUNTY ENVIRONMENTAL HEALTH [itPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q �� fi �lbb��' �7- SrR <br /> OWNER/OPERATOR ` 1 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SIIE ADDRESS <br /> rvumoer Dlrectlort I Street Name Ttodl' <br /> CI Zi Code <br /> HOME or AILING ADDRESS (If Different from Sit Address) `y •V_C'� )�e � <br /> 3 _ Street Number Street Name n <br /> CITY � �� , � ^ STATE n r I ZIP <br /> P 0 E#1 ExT. APN# Q Z. LAND USE APPLICATION# <br /> P ON 42 EXT. BOS DISTRICT LOCATION CODE <br /> \ CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /T V, CHECK If BILLING ADDRESS <br /> BUSINESS NAME p N # EXT. <br /> HOME or MAILING ADDRESS FPM <br /> CITY I J )�} STATE ._ ZIPC v �-0 <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, Standard TE and FE7' AL laws. <br /> ;APPLICANT'S SIGNATURE: -k DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER)4 OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirtc <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 <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: "�G7 C��/�S /' ��`� Viet) <br /> COMMENTS: `/.., <br /> G c �P T} �� C© • 201 <br /> 47 <br /> (y n CJ R'�JOAQUIN <br /> EA(VIR OU <br /> HEALTH DC"A TA��' <br /> ACCEPTED BY: , EMPLOYEE#: DATE: <br /> iz S-/-7 <br /> ASSIGNED TO: n q EMPLOYEE#: DATE: <br /> Date Service Completed (i (ready completed): SERVICE CODE:L5 P/E: <br /> Fee Amount: �— Amount Paid �`� f �r Payment Date —j <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />