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SAN JOAQLI•COUNTY ENVIRONMENTAL HEALTH I•ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU ST# <br /> P5-�A44V"111",f c��pb7» �� <br /> OWNER/ PERATOR <br /> r CHECK IF BILLING ADDRESS <br /> FACILITY NAME <br /> mo m,koi P1 / / <br /> SITE ADDRESS �tiM CIUb Blind -dl 5���1 q��►9 <br /> Street Number Direction Slr¢¢t Name I ZI Cotic <br /> HOME or MAILING ADDRESS (If DVi� ent from Site Ad/d7ress) q <br /> gQO O r� I'1 V Q S/vof Street Number Street Name <br /> CITY L h Rop CX} 4.PS'33a <br /> PHONE#t ErT. APN# LAND USE APPLICATION# <br /> PHONE 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , ! /J <br /> rI,ZZ0 CHECK If BILLING ADDRESS <br /> BUSINESS NAME m 0M f I PHONE# EXT. <br /> HOME or MAILING ADDRESS /'/ FAX# <br /> S8/ l?ka01ChLitz cr Pvc) ( > <br /> CITY / O p �ATE ZIP 4S•�l l O <br /> 4 K <br /> BILLING ACKNOYJLEDGEfdENT: 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 and FEDERAL laws O� <br /> APPLICANT'S SIGNATURE: /�o v1G�cet� 91InDATE: <br /> PROPERTVIBUSINESS OWNER�. OPERATOR/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, 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: cc' d(-- PAYMENT <br /> COMMENTS: RECEIVED <br /> AUG 31 2016 <br /> SAN JOAQUIN COUNTY <br /> ftB : <br /> AL <br /> HEALTH MENT <br /> ACCEPTED BY: /7. 1 EMPLOYEE#: <br /> ASSIGNED TO: 6U)-%(--,r,('Z4 EMPLOYEE <br /> EMPLOYEE#: �Date Service Completed (if already completed): SERVICE CODE: � 0Fee Amount: V Amount Paid ("( , ob Payment DatPaymentType Invoice# Check# d,a••L. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />