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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> U F UCSD q&P l7� i Oil <br /> OWNER / OPERATOR \ <br /> (� SC, � l t �, PC 1 � I Yvkw , CHECK If BILLING ADDRESS O <br /> FACILITY NAME 7 �^ <br /> SITE ADDRESS 2 U '/ 2�- �', y 0 Sc vv\ 1 �� Ve_. I ' 1GrV� � � � 161533 - / <br /> Street Number Direction Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3 ? CO Cl ' ��i 2> <br /> Street Number Street Name <br /> CITY STATE CP- ZIP C <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> (S ► a) 6oa 336 a <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �L W� ( �� � CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PH # � 00 <br /> EXT. <br /> HOME or MAILING ADDRESS 3� �i� �j , (361 1htM )�; �R \V4(` r FAX # ) <br /> CITY 1 J o ( I I � STATE � ` ZIP �j 3 <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 ap&FEDERAL laws . <br /> APPLICANT' S SIGNATURE : DATE : �5 l <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required Tule <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 IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED : s G bRECEIVED <br /> COMMENTS : <br /> AUG 0 8 2019 <br /> SAN JOAQUIN COUNT" <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY : EMPLOYEE #: / [�� DATE : GA ley <br /> ASSIGNED TO : )�� O /V EMPLOYEE #: / DATE : � ei <br /> Date Service Completed (if already Completed) : SERVICE CODE : P I E : , *) <br /> Fee Amount : 52 00 Amount Paid l S 2 _ Payment Date �J <br /> Payment Type Invoice # GFte� # V3, 1C (v �? Received By : / <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />