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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L 00'KQ'K-:1- <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRE <br /> FACiUTY NAME <br /> SITE ADDRESS � treefN L t 1 t� S`� i .�"a -N13Ck,Lr� CV5 R9 <br /> `Van city 1 <br /> HOME or MAILING ADDRESS (If Different from Si?Address) <br /> Street Number W tSctrv�ame <br /> CITY „STATE EP(e 3 a <br /> PHONE A APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR � <br /> ` 11 ok'c, O'b(o i-e CHECK if BILLING ADDRESS O <br /> BUSINESS NAME J✓� � PHONE# ExT. <br /> HOME.or MAILING ADDRESS FAX# <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 application and that the work to be performed will be done in accordance with all SAN JoaoUIN <br /> CouNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'SSIGNATURE: Drc� ,k .k" DATE: <br /> PROPERTY Hu�LIKCAANT <br /> OPERATOR/MANAGER �T OTHER AUTHORIZED AGENT <br /> Iot the pALIO PARTv proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the properly 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 JoAauiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it iS provided to me or <br /> my representative. p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �4 <br /> °/® �® <br /> 1 <br /> � <br /> 0��TY <br /> ACCEPTED BY: t 1�� �l EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q �,C EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE COOE: L PIE: J_ <br /> hN <br /> Fee Amount: I�- Amount P22 . Payment Date �S <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117/08 <br />