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SAN JOAQUI�OUNTV ENVIRONMENTAL HEALTHN.49ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY 14# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING.ADDRESS <br /> FACILITY NAME <br /> ! Ca r7 17 a t-s S 3 f} <br /> SITE ADDRESS 4336 <br /> Street Number I Direction Q Street Name` ' 1' ICi ZiD Cotte <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT, <br /> APN# LAND USE APPLICATION 31t <br /> �23 - Y706 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r CHECK if BILLING ADDRESS <br /> j cL rTl-�1 <br /> BUSINESS NAME PHgNE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> 8 q-+ 19Iu' ( 1 <br /> CITY * <br /> Pi e-� TATE ZIP /)S 3 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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,Stand STATE and FEDERAL laws. <br /> J <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILGING 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atsame time it is <br /> provided to me or my representative. NY <br /> TYPE OF SERVICE REQUESTED: -F•po C'�IM <br /> COMMENTS: u5 -t`�S 8 2016 <br /> SAN <br /> HE EMO oA,1r 0UN <br /> ALTH DEAA,, AL <br /> en <br /> ACCEPTED BY: EMPLOYEE M DATE: - )5_ ) b <br /> ASSIGNED TO: EMPLOYEE#: DATE: ,l_ C, 1]v <br /> Date Service Completed (it already completed): SERVICE CODE: O� PIE: <br /> Fee Amount: g 0 Amount Paid-? j 6,0� Payment Date r g <br /> Payment Type Invoice# Check# Rece ved ray: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />