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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 06�ar� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 'Z&Z 4- y� `�x�.�r\ Ll1 <br /> `f- *110 �l�Z. 04-Z <br /> Street Number Direction Street Name city Zip Code <br /> lir MAILING ADDRESS (If Different from Site Address) e� tree Q <br /> S�e N 1 G�y S J 1 Street(Tame <br /> CITY /,` � �f 11<Z STATE „ w ZIP n� <br /> PHONE#1 EXT. 7N# LAND USE APPLICATION# "V <br /> (S(b) SCel - 01 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> R / SERVICE REQUESTOR <br /> REQUESTOR /1 <br /> yewy CHECK if BILLING ADDRESS <br /> / N <br /> BUSINESS NAME Gr f —a:hC— PHONE# EXT. <br /> +19ME or MAILING ADDRESS FAx# <br /> I3 I ) <br /> CITY YY7,\h C a <br /> STATE (: ZIP CF o <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,Standard EDERAL laws. <br /> APPLICANT'S SIGNATURE: — DATE: 1 <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required itte <br /> ALiTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1 R ZA &I <br /> COMMENTS: <br /> � <br /> SAY 18 2015 <br /> kq FgNTV1tt p 1N, Ou TY <br /> '►ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 'D_1 j y <br /> J <br /> ASSIGNED TO: ��Q n/1 Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P✓I E: <br /> Fee Amount: Amount Paid3q0 — Payment Date <br /> Payment Type ✓ Invoice# Check# 3;2— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />