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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDP.ESS <br /> V'1 So <br /> FACILITY NAME O C O V r+--7O Q&� e A /tM F- <br /> SITE ADDRESS W [u�L S _ L N , t�� Srp OCTO 10 9$ 209 <br /> 32- Street Number Direction L tree(Name cl ZI ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stret Name <br /> CITY STATE ZIP <br /> PHONE#11 Err. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> vi r- 5 <br /> BUSINESS NAME eVC <br /> WICAICa <br /> PHONE# En' <br /> S o2 z 2 - yL{SZ <br /> HOME Or MAILING ADDRESS FAx# <br /> 25V MM L- N ( > <br /> CITY / pC O STATE ZIP el52067 <br /> BILLING ACKNOWLEDGEMENT: 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 /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � _ � -tp-- DATE: l Ip 1 b 1 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR i MANAGER ❑ \ 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, 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 /> 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: CJ ' <br /> COMMENTS: <br /> RECEIVED <br /> NOV 17 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: 1,06 Cr EMPLOYEE#: H P MFS T <br /> ASSIGNED TO: EMPLOYEE DATE: i \- )-7- ) 1 <br /> 1 ) _ <br /> Date Service Completed (if already completed): SERVICE CODE: �' 2� PIE: r <br /> Fee Amount: '-1 I--)CO 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 /> S <br />