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SAN JOAUUIN COUNTY ENVIRONMENTAL HEALTh DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> oCSSE4LT r NC 0 CHECK If BILLING ADDRES <br /> FACILITY NAME n n1`V „ 1 Jt <br /> SITE ADDRESS V �, I`-'v�l�t � �� <br /> �o Street Number Direction V Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Jtx- Street Number Street Name <br /> CITY ` STATE cl 1 ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# U <br /> (5r0) 76(e0933 v� <br /> PHONE#2 EXT. BOS DISTRT� LOCATION CODE <br /> (90) 2-01.c 037q 11 <br /> l/1r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J�C�i � / S/ , I c <br /> `J C/l� '�/{lJ J CHECK If BILLING ADDRESS <br /> BUSINESS NAME � / i 1 C ,��` n`n r ! n I/1 4 ' PHOJUE# �\ ,,•�7 ExT. <br /> HOME or MAILING ADDRESS V C— 4J1�—V V l�C'� FAXS# C/ j <br /> CITY —f/ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: jl, 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. <br /> APPLICANT'S SIGNATURE: DATE: �V/J�/ —7 <br /> PROPERTY%BUSINESS OWNER OPERATOR%MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICAN %S 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 rebase 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. <br /> TYPE OF SERVICE REQUESTED: E® <br /> COMMENTS: <br /> OCT 31 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: LD t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ' <br /> Fee Amount: GJ�o Amount Paid L{S G _ Payment Date d• 3 <br /> Payment Type G Invoice# Check# C)S Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />