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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i'e5 rogi55C <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> M I-�--) <br /> FACILITY NAME <lBOWL <br /> NC<) E +1 10 USF- <br /> SITE <br /> SSSITE ADDRESS N L-- <br /> vl�-�r r��- �C��V) <br /> Street Number Direction ret Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> L �Y e w,/A-' Street Number Street Name <br /> 14 <br /> CITY G�Gr`t ,n^ �� ' C� q �O 2—E5STATE ZIP <br /> PHONE#1 v, V Y 1 1 VEXT. APN# LAND USE APPLICATION# <br /> (( to 55-5 _ 96 1(�) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( �z� 2-6- 7,,5- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / } CHECK if BILLING ADDRESS <br /> BUSINESS NAME Iv\ PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application andthe ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa E a d- EDERAL laws. <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 to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ 'te assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the 111 lis <br /> provided to me or my representative. ry� Nr <br /> TYPE OF SERVICE REQUESTED: 16;1 vet <br /> COMMENTS: ?0'o <br /> qftjRIN <br /> O)VWN DN <br /> Dep�TMFNT <br /> ACCEPTED BY: G. M ,j a p 7C-_ EMPLOYEE M DATE: 1 a,�D.. I C1 <br /> V <br /> / <br /> ASSIGNED TO: C-e \1 <br /> C) <br /> EMPLOYEE M DATE: 11 a_ O :) Cl <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: O <br /> Fee Amount: 5a Amount Paid c:= Payment Date f �� <br /> Payment Type ;; Invoice# Check# Received By: <br /> EHD 5 G� V O `—� ` — �� SR FORM(Golden Rod) <br /> REVISEDSED 11/11/17/200305 <br />