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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME J K V( J C— �� 1�� ) �� 0 �--r 'j <br /> $ITE ADDRESS 1.1"TY! i� Iv . �-���rl Cc << D{-J <br /> 1 <br /> (J `- Street Number Direction Street Name city zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 3 <br /> FxT• APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR lP <br /> � C I f D � � 1 CHECK if BILLING ADDRESS <br /> BUSINESS NAMEI< v I L P� _ -7 EXT. <br /> HOME Or MAILING ADDRESS6(�� n/ L � \, / Tr � ( # <br /> ) <br /> CITY IC l v � I STATE /, 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It 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: LC. U HAV1NElv <br /> COMMENTS: EI1) <br /> DEC 3 0 2016 <br /> �c.,�>J C� ��� sA,v JOA <br /> QUI,, <br /> T, UN <br /> HEALTH DEPAR AL <br /> ACCEPTED BY: C.`n� �/, EMPLOYEE#: DATE: <br /> ASSIGNED TO: 6`•Illrt/11 ��2 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 4 P/E: fir�� <br /> Fee Amount: P-2C Amount Paid ���_Q Z� Payment Date 1 30 1 <br /> Payment Type(� Invoice# Check# gb a"� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />