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SAN JOAQUIN. IUNTY ENVIRONMENTAL HEALTP ?PARTMENT <br /> .� SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR j� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 /4 1 PRc\,ttL UIL I'- F�.Gd Cy,,Uck q 1 `r• I•L� <br /> SITE ADDRESS 93 o i= ✓2To r �oC C� �` SJ p C <br /> 1 Street Number Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) jZ �%/c.n �e S G i r J-c <br /> Street Number Street Name <br /> CITYI CI� �� STATE ZIP �-f z CD G <br /> PHONE#1 rO I Em APN# LAND USE APPLICATION# <br /> 1251 953-8 93 <br /> P14ONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> (zv ) 9Y8 4ylZ 3-2--2— <br /> CONTRACTOR <br /> zzCONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 114, <br /> /< CHECK II BILLING ADDRESS <br /> BUSINESS NAME <br /> �J 1 I PHONE# En. <br /> I)G/I �cci�`C I-C I ✓'» t c� µ.. ,sc.. Ic-�_S Zoll q73 —�7 c/3 <br /> HOME or MAILING ADD(RES FAX# <br /> /fz F. -4 k tJcS+ Gl .�(� (55'91732 -o017 <br /> CITY S� ti Cts S)20 I STATE 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 <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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. 7 <br /> APPLICANT'S SIGNATUR&e/��� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER L7 ' 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 <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: <br /> COMMENTS: '� RECEIVED <br /> FEB 01 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z C I L.0 <br /> ASSIGNED TO: ( EMPLOYEE#: DATE: �5f[/I W <br /> Date Service Completed (if already completed): SERVICE CODE: —<�AqS I <br /> P I E:Z <br /> Fee Amount: —C0 Amount Paid S $s— C Payment Date O a/* I f 6 <br /> Payment Typev; Invoice# Cfieelo-# a Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />