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SAN JOAQU.`--OUNTV ENVIRONMENTAL HEALTL __, PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (Ail aL1;r6 F G/L1 / t `3� 06 ��1�P�i <br /> OWNER/�OPERATOR <br /> C.e J/ G CHECK if BILLING ADDRE55O <br /> FACILITY NAME CD S'TGd �lv S� <br /> SITE ADDRESS <br /> .7Z S� Street Number Direction Street Name Ci Zi Co e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Neme <br /> CITY STATE ZIP <br /> PNONE#1 ExT. APN# LAND USE APPLICATION# <br /> c 1L36 oa L <br /> PHONE 112 En. BOS DISTRICT / LOCATION CODE <br /> I 1 05 r&-Ct <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �c�A e � CNECK If BILLING ADDRESS <br /> BUSINESS NAME ' 10A <br /> PLY 0G. PExT <br /> g/6 p�cD <br /> HOME or MAILING ADDRESS Pf FAX# / O <br /> 30 1"Awv Ave STe °S (9/b 1 laYlo_94�8,3 <br /> CITY 5 <br /> ,t'A4 1414-TO STATE ZIP 9"58 <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 /> 1 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: DATy::r pE3- 7- f <br /> I=4 f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT rKOS<<T /�'W.✓W�r�N <br /> IfAPPL/CANT 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: U �-c �E <br /> COMMENTS: e. <br /> MAR 18 2015 <br /> lif TV F?Rp MEIy�U <br /> �EPARTME <br /> ACCEPTED BY: EMPLOYEE#: DATE: / O <br /> ASSIGNED TO: EMPLOYEE#: DATE: d <br /> Date Service Completed (if a eady completed): SERVICE CODE: PIE: Z30 <br /> Fee Amount: Amount Paid 'O DDPayment Date <br /> Payment Type Invoice# Check# ,' �'�7(, ec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />