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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ------- --- <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> ��> Cam cl-��sv, , �---- �°a5 ices go°��7rog <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ` S W` ^C�.S t ��✓n C- <br /> V-10 <br /> 1� <br /> SITE ADDRESS '� �'7 S C V 1��0 l�>°� <br /> m <br /> Number Direction Street Nee city <br /> Zi COAe <br /> 0 Or MAILIN DDRESS (//If��Different from Site Address) <br /> V� r, Street NurStreet Name <br /> CIN e���- STATE ZIP l�� <br /> PHONE J ApN ---- LAND USE APPLICATION✓Y ` i <br /> � � <br /> PNONE#2 Eu. SOS DISTRICT LOCATION CUDE <br /> I I —. --CONTRACTOR / SERVI_CE REQUES_TOR <br /> RE TQ�UES OR (�` ��W, CHECK If BILLING ADDRF.ss I <br /> `J ` PMONEg <br /> BUSINESS NAME ` C �r \ 00\n <br /> 3\ '7' ^C — ,�,q, <br /> Ho E o At ADDRESS J �J Vrin �Lil �S(—# u) <br /> CRY L�� STATEZIP �t �' <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 141:1\1-m DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this fonu. <br /> I also certify that 1 have prepared this application and that the work to be perfemied will be done in accordance with all SAN JOAQUtN <br /> COUNTY Ordinance Codes,Standards,STATE�Ild FFDERAt,I[nvs. <br /> APPLICANT'S SIGNATURE: --- ---rr��--- ---- DATE ----------- ---. <br /> PROPERTY/BUSINE.SSOWNERO OPERATOR/MANAGER 0 OTHER,%I!TIIORILEDAGENIO _—_,—_.`*.- <br /> /f APPLICANT is not the B1LfJNG PART);proof of authorization to sign is required Tide - <br /> AUTHORIZATION TO RELEASE INFORRIATION: When applicable, 1, the owner or operator of the property located W W, <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asseCsnlent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMEN7:4L HEALTH DI+.r ARTMLNT as Soon a:: it IS available and at the Same time it i% <br /> provided to me or my representative. <br /> r— <br /> TYPEOF SERVICE REQUESTED: (f1 CGtilsw(fuf-t PAYMENT <br /> I <br /> _ _- -.-- -RE-CE VEL7- <br /> COMMFNTS: <br /> MAY 0 2 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPT ED BY: <br /> EMPLOYEE.# ---- ----_- DATE: <br /> ASSIGNED TO: w EMPLOYEE#: DAA' 2 Flo <br /> --_ � - -F—__ <br /> Date Service Completed (if already complete SERVICE CODE: .Cl-6(01 --�PIE: ��n 1i <br /> Fee Amount: j'j�p-� Amount Paid �. Payment Date <br /> Payment Type GV— Invoice# ---_ Check# ��r'3 Received By:Z <br /> EHD 48-02-025 SR FORM(Gciden Rad) <br /> REVISED 11/17/2003 <br />