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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 T OVOA S rO ;)- <br /> OWNER/OPERATOR <br /> OWNER/OPERATOR /�'MFCT^�� Sf Arq !'_,/ V I CHECK If BILLING ADDRESS <br /> FACILITY NAME l I—(:z Ud R CI T y0 <br /> SITE ADDRESS ,t 5 FL w L(a SE 11717,E A v[' 177,4/V rE( /f 9533 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Differen m Site Address) // 1/ <br /> lre'4-KWOQd 1 e umber Street Name <br /> CITY T� STATE 6A— ZIP 7 -� <br /> PHONE#1 / EXT. APN# LAND USE APPLICATION# <br /> (20) 740 f 39/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (90) gGti acti3 <br /> 11 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t?7EIY,4I.. Sl r' I '&) I./ <br /> ICHECK if BILLING ADDRES <br /> PHONE# ExT. <br /> BUSINESS NAME 7—0, 0 39 <br /> f <br /> HOME Or MAILING ADDRESS (y 2 W YoSE'�lrE A v�' (AX# ) <br /> CITY STATE C4 ZIP 95 3 5,7— <br /> BILLING <br /> ,7—BILLING ACKNOWLEDGEMENT: 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 /> 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, Standar , TE and FEDERAL laws. r <br /> APPLICANT'S SIGNATURE: �- DATE: <br /> PROPERTY/BUSINESS 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, 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 /> 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. `pp <br /> TYPE OF SERVICE REQUESTED: M�rtl <br /> COMMENTS: E® <br /> r OCT z 2017 <br /> S EAI OAQUIN C <br /> HSL H EPAENTANTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: I V( n <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: V I PIE: (P02-- <br /> Fee Amount: 1 Amount Paid tf, 6-2 , -- I Payment Date 10 �7 <br /> Payment Type ✓ Invoice# Check# S3 a� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />