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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SPOM loo <br /> OWNER I OPERATOR <br /> ' e,y e ` CHECK If BILLING ADDRESS <br /> FACILITY ME c <br /> I _ <br /> $ITE ADDRESS �X J �ashlhI�oh S� S-li totem a52aZ <br /> Street Number Diredlan tenet Name cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY h STATE G 4C ZIP (q <br /> (S^_1 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (40% 661 � �I1 <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> �„cAwAio <br /> Z <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> l ) <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 appT'catl n nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT d EOERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: &? it I Z 6 17 <br /> PROPERTYI BUSINESS OWNER PE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IT APPLICANT is not f e BI ING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prope located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environ )e' i formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same telt I O me or <br /> my representative. (` /���d IV <br /> TYPE OF SERVICE REQUESTED: S 'e CA 10 V-1w,SEP <br /> COMMENTS: SA/v JO <br /> ENVIROUI N COON <br /> NEACTHO PqR MENry <br /> ACCEPTED BY: - EMPLOYEE M DATE: <br /> ASSIGNED TO: YJ EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (Xf PIE:I �U� <br /> 'Fee Amount: CJa -� Amount Pal �s�,vv Payment Date �r <br /> n <br /> 11-7 <br /> Payment Type Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />