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SAN JOAQUI.,i COUNTY ENVIRONMENTAL HEALTH GtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYI # SERVICE REQUEST# <br /> Serdi� V, , ( o SP, tP �-;I1 --�l <br /> OWNER/OPERATOR <br /> CI S J1 L� CHECK If BILLING ADDRESS O <br /> FACILITY NAME w <br /> SITE ADDRESS �.�,v 1/, ���3 <br /> Street Number Direction V1 f V, Street Name W"'Cl ZiD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) PVV/'1 >�X �j* l <br /> Street Number Street Name <br /> CITY Ci STATp5Z 0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ce) I - 1 <br /> HOME or MAILING ADDRESS FAX# <br /> P6S�1 ( ) <br /> CITY �,` STATE ZIP <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 ap Iona ait7 <br /> theormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATE an DERAL <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OrPERATOR/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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. <br /> . eATA <br /> TYPE OF SERVICE REQUESTED: Ll I 47 6 k1e <br /> COMMENTS: a <br /> C4'l�irl �� �vJ�1-ems 4rW' °� 201 <br /> S <br /> EF OAQU!/y CV/ROOON <br /> LTH D oA2T7AL <br /> ACCEPTED BY: EMPLOYEE#: DATE: — '7 , / <br /> ASSIGNED TO: .. EMPLOYEE#: DATE: L4 – J <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: tr 6 <br /> Fee Amount: j (' Amount Paid Payment Date 47'--11 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />