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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ,Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l e6 uou� �3o S'k011� ��v <br /> OWNER/OPE T I <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME 5 <br /> -�ea I✓r.� <br /> SITE DD S �p �, A <br /> Street Number Direction l� .yNaQ V C i ZIp Code <br /> How or MAILING ADDRF" Rife Address) Street Number )(%treet N�e <br /> CITY +r _ C STATE <br /> ( ZIP <br /> PHONE#1 EXT. APN# LAND USE A"PLICATION# <br /> \ ) _2_ `?5 <br /> i PHONE#[ EXT. OS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERATICE RE-QUESTQR <br /> REQUEST OR <br /> Y`! � � CHECK If BILLING ADDRESS <br /> o _ <br /> BUSINESS NAME 5 CCt L / �CL <br /> PHONE# ExT. <br /> HOME or MAILING ADDRESS l V� FAX# <br /> CITY STATE /r� ZIP c�7 <br /> _ l�- <br /> BILLiNG ACKNOV'VLEDGEMENT: 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 ZhI, ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE a APPLICANT'SSIIGNATURE: r DATE•PROPERTY/BUSINESS OWNER❑ OP AT R/ OTHE ORIZED 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 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 Ivided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: .�or G h6 O <br /> COMMENTS: SO <br /> N A�0gQVIH 2016 <br /> ITh°F qR M��� <br /> FNr <br /> ACCEPTED BY: Q q Of 1-1 <br /> EMPLOYEE#: DATE: <br /> I G' ) <br /> ASSIGNED TO: Ip U� EMPLOYEE#: DATE: Iv�l S <br /> Date Service Completed t(iff already completed[)): SERVICE CODE: SC UL I P/E: f/Q'J� _ <br /> Fee Amount: J I ?�q Amount Pa' �� Payment Date rb lit V <br /> Payment Type Invoice# Check# I l Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />