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II <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5IZOU751a-5 <br /> OWNER I OPERATOR CHECK if BILLING AoDRes5� <br /> FACILITY NAME 13 Z yn 4y" <br /> 1 � <br /> SITE ADDRESS '2."1 Y n��� G5 <br /> Street Namber UlreGtion _ Street Name cityZI Code <br /> HOME Or UJARING ADDRESS (If Different from Site Address) <br /> 3083/Qn i <br /> .6 S '11'rPO� Street Number � Street Name <br /> CITYSTATE C� ZIP OIS 3 c�� <br /> T-Y�L C <br /> PHONE#1 E-- APN# LAND USE APPLICATION# <br /> (2-0pt) cQ -3123 <br /> PHONE 12 ExT• BOS DISTRICT LOCATION CODE <br /> _ <br /> CONTRACTOR 1 SERVICE : EQUES1'OR <br /> REQi1ESTOR y <br /> CHECK if B1LLfNG ADDRESS <br /> BUSINESS NAME `J PHONE# EXT. <br /> �32 �m ;in; ,mast k� Zo CP y o —sem 3 3 <br /> HOME or MAILING ADDRESS FAX# <br /> 30$3f- S ),A <br /> CITY 7Y-t-C STATE G-f�, zip q53()—1� <br /> BILLINGS 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,STAT andel %DERALlAPPLICANT'S SIGNIAT€�RE: �I /�,� DATE: CP Z-7 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPL1cANT is not the giLLwg 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 info.:nation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It IS provided t0 rile .)r <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: i V(J� <br /> COMMS;T5: UP <br /> JUN'2 7 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH IDEPAnTMENT <br /> ACCEPTED BY: ltAAAM Q{ (A EMPLOYEE#: DATE: r�_ <br /> ASSIGNED TO: t 11 k rV V EMPLOYEE#: -�Y DATE: /0- /] <br /> Date Service Completed (if already completed): SERVICE CODE: C C u � P!E: <br /> Fee Amount: APaid ad J <br /> � �l O � �3 p Payment Date <br /> Payment Type l invoice# Check# Received By: { ' <br /> EiiD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />