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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type <br /> /of_Business or Property h�lF(A�CILIITY ID# SERVICE <br /> ]REQUUE(S�T# <br /> L5 tz C'Ce' y S-} o/ c t:7A IC <br /> V uV /u I f fV <br /> (s OWNER I OPERgOR <br /> I r! C rCHECK If BILLING ADDRESS <br /> ll FACILITY NAME \ IO� &-DCC-y '�)uPe-y <br /> 517E AD RES AJ , //�1 f d.J �i/ � p L(/ r '��( 1 7- 61) <br /> V b Street Numb Dlireatlon (/" Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOGATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� GG� { t CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> 19Z5 <br /> V01 4/` 6 . 3 Fb o <br /> HOME o/MAILING Q* ek, u. ! ` S G r-t Gi/ (I p! <br /> CITY sil-e; C 9f (J,,J W&-,6 CP rx 0'+4" { STATE M ZIP 5' (}� <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 busing identified on this form. <br /> also certify that I have prepared this appl' ation an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST E and F RAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> I <br /> PROPERTY I BUSINESS OWNER❑ OPERATO / NAGER ❑ OTHER AUTHORIZED AGENT El <br /> !f APPLICANT is not the BILLING P 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 above <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 Irovided to me or <br /> my representative. !r' <br /> TYPE OF SERVICE REQUESTED: Effid <br /> l r� 'I� � E Y <br /> COMMENTS: Y 2016 <br /> SAN Nv OMECOt1Nry <br /> HEI4L7F!f1�Fgp-7-AEI�T <br /> ACCEPTED BY: EMPLOYEE : DATE: <br /> ASSIGNED TO: Lmlh(k1ri EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C PIE: <br /> �Z <br /> Fee Amount: �j Amount Paid�l (� Payment Date <br /> Payment Type Invoice# Cheek# -fow>7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> l <br /> 07/17/08 <br /> II <br />