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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> =i S� <br /> OVVNERj OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY N G <br /> SITE ADDRESS —^ <br /> Street Number Direction Street Na Ci Zi Code <br /> T71 <br /> HOME Or MAILING ADDRESS (if Diffe ent from Site Address) <br /> !�7 r /'U Street Number Street Name <br /> CITY STATE ZIP <br /> - l <br /> PHONE#1 -7 EXT. APN# LAND USE APPLICATION# <br /> & 3,',s--- ' 7� <br /> PHONE W2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORV aA ' e YL(ZC�Y-` CHECK If BILLING ADDRESS■ <br /> BUSINESS NAME <br /> EXT. <br /> Ta 1 U �� tv h2 >C� P"uB3 L1 '5-L l 1'4 <br /> HOME Or MAILING ADDRESS FAX# <br /> ` ( ) <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 /> also certify that I have prepared this applica4ioLVand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Orawance Codes,Standards,SFEDERA aw . <br /> APPLICANT'S SIGNATURE: L <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERIAT / AGER ❑ OTHER AUTHORIZED AGENT ❑ / �— <br /> If APPLICANT Is not Elle BILLI G PAR /,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 ISe_d to me or <br /> my representative. � � <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: (J V �'` V� � �� <br /> ` Ct ?9 X19 <br /> �RONM COUN <br /> �)Y <br /> ACCEPTED BY: - I VVQV�Qr� EMPLOYEE DATE: (/ —2 <br /> ASSIGNED TO: Cure EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: r 11. PIE: (�oZ <br /> Fee Amount: 1 Amount Pa O�) Payment Date 2 l <br /> i <br /> Payment Typ Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />