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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> • 12 C (CcatY, V� �f�L`67�6L1�5 <br /> OWNER/OPERATOR <br /> CHECK If BILLING AODRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS r{C- Q nSt-1 oL/GV-Ji-� ' <br /> 1 Slreet Number Directioncity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) .(1�' <br /> Street Number �� IJ+*e4t Name <br /> Cl' STATE �� <br /> C � Yl C-Ps <br /> PHONE#f EXT' APN# LAND USE APPLICATION# <br /> (gtcd 83a - 7 IOLID$bo�6 <br /> PHONE#2 EXT. BOSSDISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOg <br /> /\ rf-cry — CHECK If BILLING ADDRESS <br /> BUSINESS NAM T PHONE# pp EXT' <br /> `�V I •2A 0 - 7 <br /> HOME or MAILING ADDESS 1� FAX# <br /> C - ( ) <br /> CITY \ \ ' STATE Zip <br /> rtO /- r �-f <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 application and that the work to be performed Will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and.FOER ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER l70 OP RATORIMANAGER ❑ 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same timIs provided to me Or <br /> E`.,Lt <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: Pliny, L CES <br /> COMMENTS: pE� 12 2017 <br /> � AQUIN CO n, <br /> HEALTH EP�T NT <br /> ACCEPTED BY: 0 <br /> EMPLOYEE#: DATE:bal c�7-)::2-- <br /> -7 <br /> ASSIGNED TO: EMPLOYEE III: DATE: /�a 17 <br /> Date Service Complete (if already completed): SERVICE CODE: r]�7� PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type �� Invoice# Check# Received y: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />