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I <br /> SAN JOAQ N COUNTY ENVIRONMENTAL HEALTH ODEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hey i 'r4moto('9 ' <br /> OWNER I OPERATOR <br /> ,`� CdrwcA <br /> CHECK if BILLING ADDRESS <br /> FACJUTy NAM k" ohn V TI I , <br /> i <br /> SITE ADDRESS 1 ti� , ` 1 ' �C ( -� Cy --F-av v 5 3 f <br /> l W VIS O <br /> Street Number Direction Street Name City Zi Code i <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> s k+0 s2 as <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> ('92$) 331 ----T 41 to <br /> PHONE#T. EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUES$OR <br /> REQUESTOR <br /> �GISSGIY�C�YGCC`CA CHECK ifBILLING^4DORESS� <br /> �J ■ <br /> BUSINESS NAME PHONE# EXT. I <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> I CITY +J C STATE( An ZIP q< <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 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 a d FEDERA laws. <br /> APPLICANT'S SIGNATURE: DATE: 3-8 - / &, <br /> PROPERTY I BUSINESS OWNER CI OPERATOR i MANAGER OTHER AUTHORIZED AGENT CI <br /> IfAPPLICANr is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHOR17-ATION 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 environmentallsite 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 t0 me Or <br /> my representative. �►/�{� w'T <br /> TYPE OF SERVICE REQUESTED: Ori PAYMEN i <br /> COMMENTS: RECEIVED <br /> o s 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: N(6 I I <br /> ASSIGNED TO: �gdeG(jNn e h�,e5 EMPLOYEE##: DATE: 3 g/ l l�w <br /> Date Service Completed (if already completed): �l SERVICE CODE: (,gE P/E: <br /> Fee Amount: f��-C9,1) Amount Paid PaymentDateO :51/0 <br /> Payment Type Cc� Invoice# Check# Received By: <br /> v 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) i <br /> 07/17/48 <br />