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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID It SERVICE REQUEST# <br /> OWNER I OPERATOR - . o CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �a fi IC <br /> SITE ADDRESS w ' Cwt �i/'C✓l-��I S t ree'�� ��� <br /> Sheet Number OlrecHon Strea Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street--- <br /> CITY STATE ZIP <br /> PH NE#1 E'tT APN# LAND USE APPLICATION# <br /> ('6 333 X33 /'706�) <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST ORa+ <br /> CHECK if BILLING ADDRESS <br /> l � �� y <br /> PH "'BUSINESS NAME V13 O <br /> HOME Or MAILING ADDRESS 2 8 4 S vU C R,r Y, P L FAX# <br /> CITY f'�?0 o trztILl ' O tC-S C_ STATE Cf4 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, and FEDERAL <br /> APPLICANT'S SIGNATURE:77 DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 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: &Ld <br /> r)(a-E,♦' <br /> COMMENTS: RECEIVED <br /> NOV'28 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTqIL <br /> ACCEPTED BY: EMPLOYEE DATE: rn <br /> ASSIGNED TO: �'� C/50 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: � � ) P/E: iiDVL <br /> Fee Amount: I Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �7, <br />