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SAN JOAQUIN #:OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR n <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L-Aq4 I ) <br /> et NXfmCberr DirecS1i,b�Sh �DDRE <br /> P, (�AtioStreet Namee <br /> Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> " ` A-0StreetNumber Street Name �^ <br /> CITY ,54STAT - ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (�M) 822-3] s <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I �J CHECK If BILLING ADDRESS <br /> BUSINESS NAME1 '1(�� r J / J �/ PONE ���_ 3155ExT. <br /> �l/� v <br /> HOME or MAILING ADDRESS FAX# <br /> bZ'�-/3 ( ) <br /> CITY a'/� y1 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 /> 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: o Io- DATE: 3 Z L- /P <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ,LJ OTHER AUTHORIZED AGENT ❑ C c o <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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: cC '• <br /> Mqp <br /> Jo 018 <br /> EIV q <br /> HEyL RO/vCO Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE: T7v1 N� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment TypF- I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />