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1, <br /> SAN JOAQth?,(COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f-tZol_oCK- F Tp'(C- D3°I11 S oo75yo <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ( I <br /> FACILITY NAME " � �oL <br /> SITE ADDRESS O/ <br /> Street Number Directio C�•�� Ne C\v C e <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> _// S/tree[Number CvStreet Name t'TT <br /> CITY C• STATECPr ZIP C`Safi 1 <br /> PHONE#1 \-1 ExT APN A' LAND USE APPLICATION# '']] <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> I ) J - 1 —1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�t <br /> 1 �O CI lI/ �� CHECK If BILLING APDRESS191 <br /> BUSINESS NAME , `C ! PHONE E'T <br /> t—oC <br /> HOME or MAILING ADORE I FAX# _ <br /> S C AZO ) S�7- � s <br /> CITY STATE C ZIP X530'7 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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. <br /> APPLICANT'S SIGNATURE: _e, Q DATE: — —I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ff K� csfZ. <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 <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 OFSERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVED <br /> SEP 15 2016 <br /> SAN JOAQUIN COUNTY <br /> q NVIROMENTAL <br /> ACCEPTED BY: lL h EMPLOYEE#: HEALT /n <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S(� q PIE`: �3VO v <br /> Fee Amount: (1 I, Amount Paid7 D C Payment Date <br /> Payment Type �1 Invoice# Check# ? <br /> Recelved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />