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F R 0 `�Z2L�'I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��s s <br /> TO 2 �r���7 5c�-� <br /> re" ET/OPERATOR El CHECK If BILLING ADDRESS LFII <br /> FACILITY NAME jam IC�® / /V P G hs '� STOV� p 7 <br /> $ITE ADDRESS <br /> Street Number I Direction Streof Nam-_ �- ,.� Ctb.� Zip Code i <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> r (a C t-' Pc N /—C'tt� ITV C Street Number I Street Name _ <br /> CITY STATE ZIP <br /> (Xb C-f} <br /> PHONE Ill EXT. APIA# LAND USE APPLIC TION# <br /> (Ga&) 912- 7 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SER1710E REQUESTOR <br /> REQUESTOR l^ I <br /> -Sud 1`c- t(-,c,v\ l o c)o—Y ( i.HcCK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> STDG bN S 51-DRE �C S�_&_z ?68'7 <br /> HOME or MAILING ADDRESS FAX# <br /> ls;, G Si V ( ) <br /> CITY 1 P C-p-T ( A ` D STATE C ZIP 9 's <br /> D 1 r <br /> BILLING ACKNOWLEDGErZENT: 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 /> COWJTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: &0— �-a DATE: D ? 12-:� ( / <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, I, the owner or operator of the property located at the abcve <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Vt INamo n <br /> COMMENTS: <br /> tisD�EPA°2 3TA <br /> sq 2016 <br /> D <br /> rM�h <br /> ACCEPTED BY: Yl d`— �/ k l G� EMPLOYEE#: DATE: q (0 T <br /> ASSIGNED TO: t l hD t V r f / (tz EMPLOYEE#: DATE: 1 J��/Wj <br /> Date Service Completed (if already completed): SERVICE COD::: L P/E: <br /> Fee Amount: Amount Pal J 3 0 Payment Date Z� <br /> v <br /> Payment Type Invoice# Check# �3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />