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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �0©83212 Sgoo7y <br /> DDRESS <br /> tr <br /> OWNER/OPERATOR — <br /> CHECK It BILLING A <br /> FACILITY NAME <br /> G-roceY DP- 1A <br /> SITE ADDRESS C - �'Y�Y� �'(� "�,��� Q C 3 a t-) <br /> _ _:_Ireeet Number Dlrec[ion Street Name CIN LI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sheet Name <br /> CITY STATE ZIP <br /> PHONE#t E. APN# LAND USE APPLICATION# <br /> 2°`b W35-3 00 <br /> PHONE#Z ErT. BOS DISTRICT LOCATION CODE <br /> clow mtfa 5133 --- <br /> CONTRACTOR/ SERVICE REQUESTOR n <br /> R�Ol1EST OR �( Z '� �1 CHECK If BILLING ADDRESS' •. <br /> BUSINESS NAME PHONE# EXT, <br /> rv,Yn °S r-rocc fie 1i 83� <br /> HOME or MAILING ADDRESS FAX# <br /> 30,6.56 (12�) � <br /> CITY vc— `J STATE f^,� ZIP 5 3o <br /> BILLING,ACKNOWLE GEMENT: 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 /> 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, Standards,STATE nd FEDERAL aws. / <br /> APPLICANT'SSIGNAiURE: _ G DATE: S/ I10 Ilp <br /> PROPERTY BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IJAPPLICANT 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 /> 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. PffMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> MAY 16 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: <br /> EMPLOYEE DATE )� 1 <br /> ASSIGNED TO: �i �m EMPLOYEE#: DATE: (p I <br /> Date Service Completed (if already completed): SERVICE CODE: 9LO01 PIE )�'L <br /> Fee Amount: 3C)'OD Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> C <br /> J <br />