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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH MEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SG--woL Z G <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS J /4[ ^�� C`LG (,(`G-L-0 <br /> 7 <br /> ( 5 (i/ Street Number I Direction ��' Stree[Name �YCI CI Z7i Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH0NE#1 ExT. APN# LAND USE APPLICATION# <br /> (ul) q(oLl- 19 9- 09L? - 250 — 19 73 -7g <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (?sit) q 7f - 317 D �L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST OR <br /> CHECK If BILLING ADDRESS <br /> ry wr��-- <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRES FAX# <br /> 52 l�c�lCww✓t fir. l2�)N4 �I414 <br /> CITY ` STATE^,A ZIP <br /> S• -0 Y <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 thispplication and that the w rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �l 15-116 <br /> PROPERTY I BUSINESS OWNERIx OPERAT ANAGER OTHER AUTHORIZED AGENT 13 <br /> (\ If APPLICANT is not the BILLING PARTY,proof Of authorization f0 Sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORfeIATION: 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 a5 soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Co su IVEG <br /> COMMENTS: JAN 15 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED By!C EMPLOYEE#: DATE: / _ J5 - //P <br /> ASSIGNED TO: J zQ EMPLOYEE#: DATE: _ _ <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: / Q Z. <br /> Fee Amount: 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 />