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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of BusinessorPrgperty FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR.I�r- VV CHECK if BILLING ADDRESS <br /> �Olh 1`'�" - l <br /> FACILITY NAME �) /�/ ;�///J ✓J y-C / / / •/ //' <br /> SITE ADDRESS t( J /v/ / C_ /�/�kY1/1�I C��- L/`� X76 IZ3 <br /> 300 Y Slr, l Number Olrectlon Street Name city Zip Code <br /> HOME Or MAILING ADDREES/ (If Different from Site Ad/ <br /> dress) <br /> Z 111- ireov'1 '-�eT Stre¢[Number Stree[Name <br /> CIN 4USTATE � ^ ZIP O <br /> TL-��-D n -�-1 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (201) 4d' gI9(v <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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, Standard�sS TE and FE / laws. <br /> dyAPPLICANT'S SIGNATURE: tltl <br /> DATE: <br /> /1� <br /> PROPERTY/BUSINESS OWNER 12 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS 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 release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 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. p <br /> TYPE OF SERVICE REQUESTED: �/ /� /r' �j PAY <br /> COMMENTS: �T'QCTtI /NS/' CYLr"^/S' /S�.6w& (J�y'N2"S� O,n-•_ ENT <br /> RECEIVED <br /> APR 0 4 2018 <br /> SAN JOAQUIN COUNTY <br /> ".,--.-ENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: T <br /> 1� <br /> ASSIGNED TO: EMPLOYEE#: DA : <br /> Date Service Completed (if air ady completed): SERVICE CODE: + PI '//-/,02— <br /> Fee <br /> 2 <br /> Fee Amount: Amount Paid moi_ - - Payment Date x <br /> Payment Type ,tLX Invoice# Check# 7: j�, i ;-� Received By <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> 07/17/08 <br />