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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propert FACILITY ID# SERVICE REQUEST# I <br /> S 9-d - <br /> OWNg1t OPERATOR <br /> CHECK If BILLING ADDRESS® 1i <br /> kyr o2� <br /> i <br /> FACILITY NAME G <br /> SIT ADDRESS `�GL2,111 <br /> ll� 9s�©� 3I <br /> Street Number Direction eet Name J ' City ZI.Gode I <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -3/// <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> eA C Gt 2 , <br /> PHO #1 APN# LAND USE APPLICATION#ExT <br /> d9�(9/� <br /> 1 OA) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE R QU STOP€ <br /> REQUESTOR ,/ <br /> (�QV CHECK if BILLING ADDRESS <br /> BUSINESS NAME .I �l/, PHONE# ExT' <br /> l �Af % -O <br /> HOME Or,MAILING ADDRESS FAX# <br /> CITY r�L- STATErA ZIP 3 y� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,Coperator or authorized agent of same, <br /> ackno\Medge 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 1 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 /> CpUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: <br /> /�j� <br /> PROPERTY I BUSINESS OWNS OPERATOR I MANAGER © OTHER AUTHORIZED AGENT 13 Z <br /> If APPLICANT is not the BILLfNG PARTY,proof of authorization to sign is required Title <br /> i; 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 ENVSRONMENTAL 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: <br /> COMMENTS: MENT <br /> RECEIVED <br /> O-LO6 FEB 16 2016 <br /> SAN JOAQUIN COUNTY <br /> �I ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: UA -/ <br /> DF <br /> ASSIGNED TO: EMPLOYEE#: I)ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G&/ P!E: d <br /> Fee Amount: Amount Paid ��. --- Payment Date <br /> Payment Type } Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 0711 7108 <br />