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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'is--Poi�N� � <br /> OWNER/OPERATOR <br /> JO p11.,, ��n-^ wl CHEGKif BILLING ADDRESS <br /> FACILITY NAME 11..A R7�ly <br /> SITE ADDRESS <br /> �reelNumb¢r Direction I � � • Stre�ame Clty � Zl ode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberStreet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2o I L4 -25-6 7- 4:-�w I <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> _ CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 R <br /> J,.,yp/,! I -�cnA� J CHECK If BILLING ADDRESS <br /> BUSINESS NAME �� Co PS \ P S16E# I _^ ExT <br /> HOME Or MAILING ADDRESS O6 ST FAX# <br /> CITY STATE IZAZIP 7 <br /> `"L r <br /> BILLING ACKNOWL DGEMENT: 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 w c to a performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 1 IQI <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER HERAUTHORIZED NT ❑ _ <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 /> 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. <br /> TYPE OF SERVICE REQUESTED: �� PAYMENT <br /> COMMENTS: RECEIVED <br /> FEB 16 2016 <br /> SAN"QUIN COU <br /> ENV U40MEW LL. <br /> H@ALTH 011 <br /> ACCEPTED BY: //. EMPLOYEE#: DATE: p - <br /> ASSIGNED TO: f EMPLOYEE#: DATE, <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 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 />