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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1001 2 S,SKO7WV <br /> OWNER/OPERATOR <br /> R- ft CHECK If BILLING ADDRESS <br /> A E < <br /> FACILITY NAME <br /> ,S ITE ADDRESS S,} SFU(✓ K vv�� <br /> 11,S 7 Street Number I Direction Street Name city Zip Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E%T. APN# LAND USE APPLICATION# <br /> QlJi) 4411 —O-77S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 � /1 Ck `�� <br /> BUSINES AM "\ CHECK If BILLING ADDRESS <br /> TPHONE _ EXT. <br /> Lcti � � <br /> HOME or MAILING ADDRESS FAx# <br /> "L( G} ( ) <br /> CITY 5 a- � STATE ,, . Zip -is <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, Standar/dl.,STATE <br /> and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: X GV DATE: 6/37 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,Proof of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 a5 soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: WMENT <br /> COMMENTS: )n A \ (,r ,� fJ �^ 1 11n n /1� RECEIVED <br /> AN u 3 2017 <br /> SAN JOAQUIN COU��N��TItY <br /> RIM <br /> ACCEPTED BY: I v EMPLOYEE M HEALTy11 <br /> H DEPART 1 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): 777JSERVICE CODE PIE: <br /> Fee Amount: 15') .C j Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />