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SAN JOAQUIN*UNTY ENVIRONMENTAL HEALTH WARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> }�,o , fpr6Co I 1�1 Co SgRpo74(0W <br /> 11 <br /> OWNER/OPERATORbu— ^\ CHECK If BILLING ADDRESS <br /> FACILITY NAME J <br /> Save 0 s �-- G✓ <br /> SITE ADDRESS L 29 �. yp �iv�+ qJ2 �4H A-Q CA gS33 '�- <br /> Street Number Direction Street Name cc�.city Zi Code <br /> HOME or MAILING AD KESS (If Different from Site Address) to �— �y eGpS yr' <br /> -� Q tW Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE41 Ea. APN# LAND USE APPLICATION# <br /> (ski ) -734- U,111 <br /> PHONE#2 Ea. <br /> BO DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME �.1t PHONE# Ea. <br /> aV.� Q✓` U01� ( 5(0) 3 <br /> HOME or MAILING ADDRESS +fit �p FAx# <br /> 20 w• XO 0,V A\ ( ) <br /> CITY 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. <br /> APPLICANT'S SIGNAT -� DATE: 'd--1 '_��� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If-4PPLiC&&isnot1heBLLLhVGPARTY 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. .y-- p' r PAY <br /> TYPE OF SERVICE REQUESTED: LA5 1 �iIwT1 ECEIVED <br /> COMMENTS: (ge,l,la��vyle{/)-�' G ,,��c� APR 19 2016 <br /> P� W' SAN JOAQUIN COUNTY <br /> ENVIROMENTAt_ <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: L[116111& <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 \/�r0 <br /> Date Service Completed (If already completed): SERVICE CODE: c $ PIE: -2 J0% <br /> Fee Amount: 4310-(D Amount Paid 3 9 C, C9 C-) Payment Date �y <br /> Payment Type C � Invoice# Check# IL l G v Received By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br />