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SAN JOAQ*COUNTY ENVIRONMENTAL HEALTHIMPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -s �,�� F S�07Qj I U3 <br /> OWNER/OPERATOR e-�Cl <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME -Ko <br /> I -6 "N`,y '3`'3s-6 <br /> SITE ADDRESS IQ �6y ,t1 „ La-wc- n� zo <br /> S raet Number Dimctlon Stree[Neme Cit CL Z otla O`• <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sireel Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME r ttc)" S -) S �� q PHO E# zw - 6/,I C E <br /> Tl. �YCCS TJ [vL3 <br /> HOME Or MAILING AD %E5 FAx <br /> © (�L(L I I <br /> CITYQ 0,�� �A Q �1' 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 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 11f(aV IlJ DATE: <br /> �� <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT TC I/E\�r(j_N�.P L'F-�"�ylY•CF' <br /> If APPLICANT is not the BILLING PARTY Proof Of authorization to Sign IS require!/ Title <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYII <br /> RECEIVED <br /> AUG 2 8 2011 AUG 2 2017 <br /> SAN JOAOUrN couN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMr_,, E� t' ..,MAL HEALTH <br /> ACCEPTED BY: EMPLOYEE III: DAM"' <br /> ASSIGNED TO: r10e EMPLOYEE#: DATEE:1 <br /> Date Service Completed (If already completed): ua SERVICE CODE: PI E: <br /> ' <br /> Fee Amount: 5 Amount Paid (D D Payment Date <br /> Payment Type Invoice# Check# Recel ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />