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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> 16e Creawt Seo S�Oo7g17 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRE55O <br /> FAdILITV NAP IE r✓�-r <br /> SL,�ee- 1 ce Cr�gr-. k ic�-+f <br /> SITE ADDRESS �� !� 1"'P74t vi, / .. Lvo) 9'S'LCAZ <br /> Street Number Direction [ Street Name `!'1 Cib 1l''�� II 2i otleT <br /> HOME or MAILING ADDRESS (if <br /> ^Different from Site Address) <br /> 2 I rt L�C Street Number Street Name <br /> CITY L oo( STATE C '4 zip <br /> PH0NE#1 ExT. APN# LAND USE APPLICATION# <br /> (, ) /O—0 ZM <br /> PHONE#2 EAT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `\ f <br /> J� CHECK((BILLING ADDRESS <br /> BUSINESS NAME _I - HONE# <br /> PEXT. <br /> SV wR �CQ CrN4V� 1 7 t� I Zcy Srlo-0288 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2y WYvC �irAFf L��N ( ) <br /> CITY C6oI STATE C �7 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 /> also certify that I have prepared this appiication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST nd FEDERAL laws. <br /> I i <br /> APPLICANT'S SIGNATURE: _ DATE: 2�9/20�6 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PAnrv,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 assessmel,t 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.TYPE OF OF SERVICE REQUESTED: faqd C'f)e'� — 'CLQ <br /> CUTAMENiSt RECEIVED <br /> I <br /> FEB 0 9 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROME_ <br /> ACCEPTED BY: EMPLOYEE#: ATE: �- WNr <br /> ASSIGNED TO: -� � �I, <br /> EMPLOYEE#: DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> J <br /> Payment Type Invoice# Check# i Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />