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G <br />} SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> k SERVICE REQUEST <br /> i Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Al- <br /> OWNER/OPERATOR <br /> 01 r I\ �a I CHECK if BILLING ADDRESS <br /> FACILITY NAME /� \5 <br /> /� a o <br /> SITE ADDRESS 'I�y$$ H�`, $ M�^�S 7 <br /> —1gC1 q5'i 175freet Number Direction 7 Street Name CI i Zi GodLe <br />!� HOMEorMAILING ADDRESS (If Diff rent from Site Ad ) <br /> i ELIUG Street Number Street Name <br /> CITYK STATE £. ZIP � <br /> Irl r <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> I 'E" M_Cs I q-Lga a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Er <br /> CA/\ f1 e—`4 C <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C ( nc- aLia-SOL( I <br /> HOME orMAILING ADDRESS [� �� FAX# <br /> Ro. y ( ) <br /> CITY 1 r-n L a//I STATE A ZIP [/ S( <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 /> 1 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 F laws. I <br /># APPLICANT'S SIGNATURE: DATE: CJ <br /> PROPERTY 1 BUSINESS OWNER❑ OPERAT R/MANAGER ❑. OTHER AUTHORIZED AGEN <br /> If APPLICANT is not the BELLING 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 result-, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and al.the Same time It is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: lbo'4 oc"—) <br /> OMtv1F.!1'S' Wr"�1U �k4A7 il{ I!e RECEIVED <br /> V-- widC 1. APR-2 6 2016 <br /> SAN JOAQUIN CUNTY <br /> HFAIN ENTaE <br /> H DEPNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ZIP11+a <br /> ASSIGNED TO: �L EMPLOYEE#: DATE: `f lllp i LP <br /> Date Service Completed (if already compl6ie : SERVICE CODE: Z PIE: �VO l <br /> Fee Amountl IIr3Gto•[� Dunt Paid 3 Gj U (� Payment Date /� 6 A/6 _ <br /> Payment Type C Invoice# ` Check# jp,r F eceived By: <br /> EHD 48-02-025 r SR FORM(Golde6 Rod) <br /> 07/17/08 �,r <br />