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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE.REQUEST# <br /> let CrcamFA0 66 <br /> %-1-t <br /> OWNER I OPERATOR y� <br /> Lg <br /> D n 4l „ ��� CHECK If BILLING ADDRESS <br /> FACILITY NAME r LUNr (!� �F���YI <br /> '✓t'�tn1 �rnt ���. <br /> SITE ADDRF�s----1--�.� j� },y�a+� S.r. yl�an�c,�t R X33,6 <br /> Sheet Number Direction Street Name cit Zip Code <br /> How or MAILING ADDRE_ ffers SS (If Difrom Site Address) \A OI Pri 13v <br /> ry <br /> - Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Y10) 331 <br /> PHONE#2 BGS DISTRICT LOCATION CODE <br /> ( <br /> G011TPACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 ., O I 'o U w.,,_ _ d„Z 11 a CHECK if BILLING ACT)RE55 <br /> BUSINESS NAME '�+rtQ aX (S�� PHONE# EXT. <br /> 3-CC U"$,A Lay�d LLL fv ; 3 ( 0611 <br /> HOME or MAILING ADDRESS FAX# <br /> f y3 b Wei Friw,&rD ( ) <br /> CITY San �oyCtA Z-0 STATE CA ZIP 11U-rh <br /> BILLING ACKNOWLEDGErAENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST a ! EOERAL laws. <br /> APP'LICANT'S SiGNAT URE: DATE: f 3- ) <br /> PROPERTY I BUSINESS OWNER OPERATO i MANAGER © OTHER AUTHORIZED AGENT El <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator Of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the Same time It Is provided to me Or <br /> my representative, <br /> TYPE OF SERVICE REQUESTED: PA1 <br /> COMMENTS: RECEIVED <br /> JUL 13 2016 <br /> SAN JOAQUIN COON <br /> ENVIROMENTAL <br /> HEALTH DEPAEITMENr <br /> ACCEPTED BY: EMPLOYEE#: DATE: -7 <br /> ASSIGNED TO: �cL- EMPLOYEE#: DATE: --7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I DO- Amount Paid I Payment Date <br /> Payment Type q I,C,Ar Invoice# Check# O�a$ 1 Received By: A)V—) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> D7/17108 <br /> i <br />