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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> \C; , }� CHECK If BILLING ADDRESS <br /> FACILITY NAME r/ C L u'T/ [) ze J C <br /> �Q SC�''S ` �i <br /> SITE ADDRESS �' ���} t:Cj �iSZDS <br /> Street Number Direction Street Narat CI Zip Code <br /> HOME or MAILING ADDRESS (If Differe t from Site Address) <br /> Sa UA Street Number Street Name <br /> CITYC TSE` ZI!�S Z( <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR If SERVICE REQUESTOR <br /> REQUESTOR / <br /> P <br /> �P ^ �y C`J C.C (. \ /— C T-/ � CHECK If BILLING ADDRESS <br /> BUSINESS NAME Y J ((( �' PHONE# ExT. <br /> 61 14 Aisc o ��c_ ���v rz d� 2�_' (<? <br /> HOME or MAILING ADDRESS /J FAX# <br /> CITY �' _� ! STATEZIP <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: Z G!J l y r 2 DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I 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'nformation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provld@ e Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: J C a 1 <br /> COMMENTS: <br /> SgNdO 20 <br /> A <br /> Llli�Ov�tE9 TyOFA';A( <br /> ?"qt RTti'SM <br /> ACCEPTED BY: �t EMPLOYEE#: DATE: . <br /> ASSIGNED TO: L EMPLOYEE#: DATE: q _ <br /> —1c <br /> Date Service Complete (if already completed): SERVICE CODE: PIE=: i HCl <br /> Fee Amount: 1 3 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />