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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> { <br /> SERVICE REQUEST <br /> Type of Business or Pr perty ( FACILITY ID # SERVICE REQUEST # f <br /> \1 I��U0031 � X433 `? <br /> I <br /> OWNER / OPERATOR ` <br /> CHECK If BILLING ADDRESS € <br /> 3 <br /> FACILITY NAME <br /> SITE ADDRESSy \nn �yly o <br /> 1j1 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) h F <br /> Street Number Street Name P I <br /> tIV <br /> i <br /> CITY STATE ZIP l CkF' 6/ <br /> PHONE #1 EXT APN # LAND USE APPLICATION # C j <br /> Q ssq -991 Z9S� vvt ta, , a QCT Mp <br /> PHONE #2 EXT ) .t � 1Liv BOS DISTRICT �l0/9QD I <br /> l 14 r ON,, UN / fi <br /> CONTRACTOR / SERVICE REQUESTOR TMEN �, <br /> i <br /> REQUESTOR Q C ECK If BILLING ADDRESS ® j <br /> BUSINESS NAME PHONNE # Ems' I <br /> (a <br /> HOME Or MAILING ADDRESS FAX # <br /> CITY . ST ZIP i <br /> i <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or bush ss owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPAR ENT hourly charges associated with this project or I <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 thha Alt e work to be performed wi I be done in accordance with all SAN JOA <br /> QUIN F <br /> COUNTY Ordinance Codes, Standards, STATE and FF2D LI Vs. ) <br /> APPLICANT'S SIGNATURE : : ter -�--- DATE : <br /> PROPERTY / BUSINESS OWNER OPERATOR Y MANAGER OTHER AUTHORIZED AGENT ❑ t <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , 1 , 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 /> to 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: � �' f J <br /> COMMENTS : <br /> I <br /> Y <br /> I <br /> i <br /> I <br /> i <br /> s <br /> F <br /> F <br /> ACCEPTED BY : r�t-71 � v� EMPLOYEE #: DATE : <br /> P G� t <br /> ASSIGNED TO : j `�� EMPLOYEE # : DATE: IU f' X ' <br /> Date Service Completed (if already completed) : SERVICE CODE : / w� PIE: . <br /> Fee Amount : o �� Amount Pai /s� ( Payment Date <br /> Payment Type ' S� Invoice # Check # 132. $3 $bb Received By ; <br /> E <br /> t <br /> } <br /> t <br /> EHD 48- 02-025 SR FORM (Golden Rod) <br /> 07/17/08 ` <br />