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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER i OPERATOR , <br /> J CHECK If BILLING ADDRESS <br /> FACILITY NAME '77� f (/�Y� Al <br /> r' <br /> SITE ADDRESS/(i ( ( /✓F�.,t% `%�' < (/ �91/ �/ 1RA94 2 - Z. // v <br /> Street Number Direction Street Name C e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip Z - <br /> PHONE #1 EXT. APNLAND USE APPLICATION # <br /> 0I ) J z51 s 4( � / 112 Oct <br /> PHONE #2 /' Exr. BOS DISTRICT ISKPoT a CODE <br /> ( r9 ) (r:J L E" E IV4AQUIN C <br /> CONTRACTOR / SERVICE REQUESTOR �rH °�P�rrai <br /> jlwlez <br /> r <br /> REQUESTOR o--- CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE # I Exr. <br /> HOME or MAILING ADDRESS fl FAX # <br /> 2� f <br /> CITY /h I] STATE 6:: / 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 /> 1 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, STA E and FED.ERA( laws. <br /> APPLICANT' S SIGNATURE : t DATE : / /aD ZD <br /> PROPERTY / BUSINESS OWNE TORI ANAGER ❑ OTHER AU , RIZED AGENT ❑ <br /> If APPLICAN ITS not the Iti LUNG PAR proof of authorization toy gn 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 IS provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : U , <br /> �I <br /> COMMENTS: et/ <br /> fee 4poglsS <br /> S %lalG )anvj Our 7" *� � <br /> ACCEPTED BY: EMPLOYEE #: (/ DATE: ��J 9 <br /> ASSIGNED TO: S �Jl /` EMPLOYEE #: T DATE: <br /> Date Service Completed (if already completed) : SERVICE CODE: ( PIE: <br /> Fee Amount: a- "a Amount Pai (f5Payment Date 01;7. <br /> Payment Type ��f" Invoice # Check # � 7 �S'l Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />