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SAN JOAL-iN COUNTY ENVIRONMENTAL HEALTr....)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />00 2C) <br />SERVICE REDUESa# <br />OWNER / OPERATOR <br />?; /4 1iI ((r,-) 1/1 ,--° f S . <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />C ( k• ( / a de U &..c C 0 CA ICA <br />SITE ADDRESS <br />CI 7 <br />t'A <br />eet Number Direction AA Street Name <br />f <br />City <br />2 / <br />Zip Code <br />HOME or MAILING ADD ESSIf Different from Site Address) <br />/ C / <br />, <br />. S--C ' )5,' e Street Number Street Name <br />CITY (,gATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />-- <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RTUEST9R <br />t- k vt-e 1 - /\''_)- <br />CHECK if BILLING ADDRESS <br />uSINES§NAME <br />Cj-(Li a ciccic.k:Sck:i c,-, <br />PHONE # <br />(oi) <br />EXT. <br />HOME or MAILING .DDRESS Fax # <br />CITY- - <br />--) -c)C: V- \rc__ <br />STATE (" ,i-F• ZIP C'ic. -,-,_ <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 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY! BUSINESS OWNER±K OPERATORAANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 is provided to me Of <br />my representative. ." <br />TYPE OF SERVICE iL REQUESTED: <br /> <br />!,C imIVED <br />COMMENTS: 06w win_ cmimAr_ i_itiii U 3 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: --\-- e. nicA,r)DeC11:- EMPLOYEE #: DATE: rl <br />ASSIGNED TO: \--0( NI 1-1- EMPLOYEE #: DATE: I <br />Date Service Completed (if already completed): SERVICE CODE: <br />' I <br />1E: <br />Fee Amount: V.3a VO Amount Paid Payment Date c6 / / f 7 <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)