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SAN JOAQU10OUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /'lg•v Rwv�- - <br /> OWNER 10 RAT4R <br /> C / l� CHECK If BILLING ADDRESS <br /> FACELITY NAMEc/�;' a <br /> SITE AD15S � ,�,.� .' ��+� ��",,�"`f•'Yt s�'"`-• <br /> Street Number Dirk n Street Ngypp Z{pCode <br /> HOME or MAILING AnORE5S (If different from Site Address) _ t s <br /> Street Number Street Nems <br /> CITYr <br /> /' f k- TATE ZIP <br /> PHONE#'1 EXT. AM# LAND USE APPLICATION <br /> PHONE #2 EXT. BOS C}[STRICT LOCATION CoDE <br /> (ft 4-16 -46 s 6 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if EILLING ADDRESS <br /> o C -tea <br /> BUSINESS NAME, ff��} /1 PHONE# <br /> L..f i✓+ t_-r'Jf/l G°G•7 /dR-- C.,M _3 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY / STATE ZIP frj <br /> Gt• `rpt //yLtc.7Z7 7 <br /> BILLING_ACKNOWLEDGEMENT: t, 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 of <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 that the work to be performed wiSl be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2i 21 <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER l ! OTHER AUTHORIZED AGENT ❑ t�N ULJtf�i� / � <br /> if APPLICANT is not the Sl INCE PARTY, proof of authorization to sign is required Time <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, geatechnical data and/or environmental/site assess /nt Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH {DEPARTMENT a5 soon as it is available and at the Satre time it IS p Ifl��/n9g� <br /> my representative. <br /> I TYPE OF SERVICE REQUESTED: Ju <br /> 4.0 C U14 <br /> COMMENTS: 1 �Xy 1 � (� RECEIVED SAN`�DpQurnr you <br /> NVIRO N <br /> JUL 2 2 2014 HCA-THDEPAaTAL <br /> MEN <br /> ;SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: DATE: 7 <br /> Date Service Completed (if already completed): SERVICE CODE: �� PIE: 330 y <br /> Fee Amount: Amount Paid aymerlt gate 7 1 <br /> Payment Type Invoice# Check# �q3 t� Received By: <br /> / t <br /> EHO 48-02-025 0 <br /> $R FORM(Ga#den Rod) <br /> 07/17/08 <br />