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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property l`ACILITY 1D# SERVICE REQUEST# <br /> >V-"3 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> FAC' 'TY NAME <br /> SITE ADDR <br /> Street Number Direction f!` $reef INamLe L l' Ci [ZI CoJde <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> }lJ Street Number �Ve ' Street Name <br /> CITY STAT ZIP ri <br /> oats �,, �5�s <br /> PHONE#1 E-- APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR 1 <br /> l CHECK If BILLING ADDRESS <br /> BUSINESS NAME I� 1 PONE# y rl 'U + 'r i 1 Ex <br /> HOME or MAILING ADDRESS FAx# l U l U <br /> CITY ( F/� STATE In ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of salve, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 he performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. r� �� <br /> APPLICANT'S SIGNATURE: DATE: 12� LZ :0 LQ <br /> OPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: kobde lud u Ot? <br /> PAlifteasus <br /> COMMENTS: Rie6� � <br /> DEC 2 2 2010 <br /> -%N JOAQUIN C <br /> NMRONIWE 7ALTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: y <br /> ASSIGNED TO: EMPLOYEE#: !0 e/ DATE: 2� <br /> Date Service Completed (if already completed): SERVICE CODE: P i E; <br /> Fee Amount: v.,f Amount Paid 1�2 �- Payment Date 2 2rL <br /> Payment Type Invoice# Check# l Received By: <br /> EHO 48-02-025n SR FORM (Golden Rod) <br /> RREVISED 11/17/2003 OV50t/l <br />