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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UcPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property /�FA�IaTY_�� 1--SERVICEOREQUEST�,g <br /> l� �- f?/ <br /> OWNER/OPERATOR <br /> t CHECK if BILLING ADDRESS <br /> l r" r I ✓ tlPf /'O <br /> FACILITY NAME <br /> SITE ADDRESS 8 �ry / 'T,r Q./S Pr-I/e. - ,S 0< ' OA/ 75 J7 <br /> S[reet Number Direction ./ Slr¢e[Name CI ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> v tZ AL Street Number Street Name <br /> CITY STATE ZIP <br /> 7776 C ?-0 Al- A c , '�' <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (W i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 t CHECK If BILLING ADDRESS <br /> aIre L)I' e7ve t/M G U fFcro <br /> BUSINESS NAME PHONE# EXT. <br /> e ✓ r^t�- <br /> HOME or MAILING ADDRESS FAX# <br /> CITY O STATE 611p 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. J <br /> APPLICANT'S SIGNATURE: Jexr/L'C'/ ���/�QnL��J �r. DATE: /a �2�/E <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,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 Is provided t0 me Or <br /> my representative. ``,�,, X9 <br /> TYPE OF SERVICE REQUESTED:` V Q V I I G.I H` I vA5 ec4i 6n PA tF <br /> COMMENTS: r <br /> �►� ,o�� iruct� LIQ � l� � 13'� v I ocT 1 � zois <br /> SAN JOAQUIN COON <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENI <br /> ACCEPTED BY: EMPLOYEE M DATE: )O_ 1a- )J6 <br /> ASSIGNED TO: EMPLOYEE#: DATE: )0_ I� ) <br /> Date Service Comple d (if already Completed): SERVICE CODE: O PIE: 1�� <br /> Fee Amount: t r Amount Paid 13q Payment Date )2 1 I• <br /> Payment Type CC$ Invoice# Check# Received By: <br /> v - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />