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USS � <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT REC;Eivu . <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES I :_ 2( <br /> f' FA U00360 <br /> OWNER/OPERATOR P'4-gm) <br /> � � <br /> �/4_g m) CHECK If BILLING ADDRESS <br /> FACILITY NAME ® , <br /> SITE ADDRESS SON W Ay <br /> Street Number Direction Street Name J C ityZi Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> 7--� C— /k.>_" "Street Num Street Name _ <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PIS �►I ►i!�)F-R M o —S N► N A <br /> CHECK if BILLING ADDRESS <br /> E. <br /> BUSINESS NAME (;I' <br /> r V PHONE# L / I / 3T <br /> HOME Or MAILING ADDRESS A (I ova FAX# <br /> CITY STATE ZIP`/ fC <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, Standards, STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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. PMMFNT <br /> TYPE OF SERVICE REQUESTED: / iA e-- RECE1VED <br /> COMMENTS: J U L 2 4 2015 <br /> SAN JOAQUIN COUNTY <br /> ENYIROMENTAL <br /> HEALTH OLPARTRAENT <br /> ACCEPTED BY: ^ I)n EMPLOYEE#: DATE: <br /> ASSIGNED TO: ( I EMPLOYEE#: DATE: V'-) f <br /> Date Service Completed (if already completed): JERVICE CODE: b OJ PIE:/,; <br /> Fee Amount: f� Amount Paid �3 0 O � Payment Date <br /> Payment Type� �J Invoice# Check# 6 r Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />