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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> jREQUEST# <br /> ' P O 11 o5� �o -/ <br /> OWNER/OPERATOR <br /> �( I CHECK If BILLING ADDRESS <br /> FACILITY NAME , t <br /> �IIQi� ssG 4 nou , UL L <br /> SITE ADDRESS 'Il �L, , ,C(7 1r j '� CA <br /> 2 5 4 5I M au nfi�t T��/1,�` C r <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ()cq) 990 1)W5 '- <br /> PHONE ill EXT. BOS DISTRICT LOCATION CODE <br /> O9qrn <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME1dk<-:'Csa <br /> PHONE# EXT. <br /> L �, I D <br /> HOME or MAILING AS FAX# <br /> a I ( ) <br /> CITY `t STATE ZIP <br /> BILLING ACKNOW DGEMENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE/#d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �; I h�L/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERAT MANAGER IJ OTHER AUTHORIZED AGENT L� Uj/J �` L/rl 1�TU <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tire <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. POl M <br /> TYPE OF SERVICE REQUESTED: RECEIVE <br /> COMMENTS: (( DEC 0 4 2018 <br /> SAN JOAQUIN COUN <br /> IY <br /> v('01 2 ENVIRONMENTAL <br /> �} HEALTH DEPARTMENT <br /> ACCEPTED BY: 4\A n EMPLOYEE#: DATE: `.L/ �- ) U <br /> ASSIGNED TO: \�\A ', EMPLOYEE#: DATE: i?-141) 10 <br /> Date Service Completed (if already completed): SERVICE CODE: i (p ( P I E: (I U w <br /> Fee Amount4 1 C52-6U Amount Paid ( 5� — Payment Date (� <br /> Payment Type V1 ` Invoice# C#te> k# / ,l(� ZS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />