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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property _ 06��C/ T �� f <br /> OWNER 1 OPERATOR CHECK if BILLING r+ADDRESS <br /> FAclurr NAME <br /> SITE ADDRESSi 2 voseim+e, A�� ��� � � e C' Zi Cade <br /> Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) Street Name <br /> Street N umber <br /> STATE zip <br /> CITY <br /> PHONE#1 ExT• APN# � ��� f f1 <br /> LAND USE APPLICATION# <br /> 510 01 /VLOCATION CODE <br /> ExT• BOS DISTRICT <br /> PHONE#2 <br /> ( <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR �a� CHECK If BILLING AflDRE55❑ <br /> PHONE# EXT. <br /> BUSINESS NAME C t_kb <br /> HOME or MAILING ADDRESS <br /> J {� FAAXX# <br /> # <br /> � � W 0��� �Ve-, <br /> CITY ! I aJ 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 lawns. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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, 1, 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 envi ronmenta Vsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the same time it I5 provided to me Or <br /> my representative. <br /> PffMIRINT <br /> TYPE OF SERVICE REQUESTED: 4 P11 LLC <br /> COMMENTS: <br /> C_V�G��.� G� o L RPR 0 3 2017 <br /> SAN,fOAQUIN COUNTY <br /> `_ ENVIRONMENTAL <br /> }HEALTH DEPARTMENT, <br /> ACCEPTED By: EMPLOYEE#: DATE: Ll <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PTAP a <br /> Fee Amount: Amount Paid l 39 , eo Payment Date <br /> Payment Type Invoice# Check# )W Z Received By: �9 � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 0711 7/O8 <br />