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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ENAME <br /> or Property FACILITY ID# SERVICE REQUEST# <br /> ',S�ORCHECK If BILLING ADDRESS 0 <br /> CI g�'cj <br /> Street Number I Direction Street Name CI Zi Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ,f'N C�t"r �� <br /> Sd Street Number <br /> Street Name <br /> LITY SY1 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( LIog �s'Ys- 1 `� <br /> P <br /> (aE�HONE#Z tin( EXT. BCS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �J 1 Q <br /> v`\�1C CHECK If BILLING ADDRES54:S <br /> BUSINESS NAMEk\-,.�ssr, 5-\-,R \Y,C.�b\C1 C- \���Y`�C-�r•c'-4 PONE# EXT. <br /> � 3- 57 <br /> HOME or MAILING ADDRRE$$ (� FAX# <br /> QSU FT d-,e I ( ) <br /> CITY cFp C_.lC STATE C(� ZIP , t� <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: G TQr DATE: ®/ ,2� <br /> PROPERTY/BUSINESS OWNER/,�J( OPERATOR/MANAGER ❑ '5 OTHERAUTHORIZED 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time It i5 provided t0 me or <br /> my representative. (`�,,, <br /> TYPE OF SERVICE REQUESTED: C U -(;t A <br /> COMMENTS: PAYMEINT <br /> RECEIVED <br /> JAN 12 2016 <br /> SAN JOAUUIN COUNTY <br /> ENVIROMENTAL <br /> HE <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: CJ-s/1 ' /'� EMPLOYEE#: DATE: 61 (27 Ip <br /> Date Service Completed (if already <br /> completed): SERVICE CODE: PIE: Q� <br /> Fee Amount: C-4) 1 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 />