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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sh067FS-�(q <br /> OVVNERIOPERATOR <br /> r. l CHECK If BILLING ADDRESS <br /> ern <br /> FACILITY NAME r <br /> SITE ADDRESS Lt1 1, , a i BE <br /> C.Ic /7 �C- ff�'("' (1S23-7 <br /> Street Number Direction f��N`I Street Name ✓7C/ (.i CI Zip Code <br /> E r M9 ING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> Lod&For , TATE W ZIP9s2-3 <br /> P ONE#1 EXT' APN# LAND USE APPLICATION# <br /> 6 /ll103 <br /> PHONE#2 Ea. BOIS DISTRICT LOCATION CODE <br /> ( ) C L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ r (.` <br /> S ,I terO <br /> (N CHECK If BILLING ADDRES <br /> BUSINESS NAME l ,( /s T &e n PONE# 2,1 � ` ExT' <br /> Ho Or MAILIN (DDD`RESS /'' r '{A FA%# 6 <br /> 7J ( ) <br /> CITY / rd <br /> STATE ZIP 952 <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 /> 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, Standardss,/STT,/AJ{��r/fit FEDERAL law�//J/� � <br /> APPLICANT'S SIGNATURE: ? ' aA-15K 4t Z� DATE: I <br /> PROPERTY/BUSINESS OWNER' OPERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY proof Of authorization t0 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 information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time it is provided to me or <br /> my representative. PAYANENT <br /> TYPE OF SERVICE REQUESTED: agd C--ons>aJ4n4ioA RECiElYED <br /> COMMENTS: o o cJ n /Ay 1 <br /> 12018 <br /> q-e. SAN JOAQUIN COUN <br /> ENVIRHEALTH p NMENTAL TY <br /> EPARTMENT' <br /> ACCEPTED BY: EMPLOYEE#: DATE: 4.-a.l . / <br /> ASSIGNED TO: ' I EMPLOYEE#: DATE: ✓-a j� / <br /> Date Service Completed (if already completed): SERVICE CODE: O(e PIE: <br /> Fee Amount: Amount Paid 2 Payment Date 512-111 -6 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />