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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Emars TA `Jlal-, cowgls-j <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS❑ <br /> oewpo <br /> s TF ,P. <br /> FACILITY NAME Wr <br /> I urgi <br /> SITE ADDRESS g131 6 VVj�F����� I`1 -- <br /> ' StreetNumber Direction "rr r'^� RO�`�Street Name Srof.KroNGi Zi Caae <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EM APN## LAND USE APPLICATION# <br /> ( ) 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I OoZ _rill O 1T <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> RD rooRT- CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> DRr Aar � JP6 -bey Z <br /> HOME or MAILING ADDRESS FAX# <br /> 525 N. 6ma Av. # ( ) <br /> CITY STATE / ZIP 9 M <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 an F EOE AL laws. <br /> APPLICANT'S SIGNATURE: — DATE:D7103 I A <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization f0 sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locatecliSt the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessilnx lift r ion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time It Is p Cpm i°fl�v <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: N✓Oq 9 <br /> TN <br /> 14 �Nq�M�U�T <br /> ACCEPTED BY: 0 vin EMPLOYEE#: DATE: v <br /> ASSIGNED TO: �FA f 1 WV EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SZ PIE: IW� <br /> Fee Amount: V Amount Paid TSI DD Payment Date `f <br /> Payment Type CI` Invoice# Check# 3Y-2,23 Rec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />