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SAN JOAQUm COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#l. SERVICE REQUEST# _ <br /> R05 10[L )b i`elf% S�- (✓ 7 <br /> OWNER I OPERATOR <br /> �� CHECK If BILLING ADDRESS <br /> P.z,;E0'/ . AI+A WA tic '4t4'--k-- <br /> FACILITY NAME 1 <br /> SITE ADDRFccA <br /> tuber Direetlon f J l tr t Name CI Zf Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> /C �" <br /> Street Number treat Name <br /> CITY STATE ZIP <br /> U CSG <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> FP(l <br /> HONE#T IT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /J / / <br /> f��'/^4" n y} � .rde p C CHECK if BILLING ADDRESS <br /> /q_ <br /> BUSINESS NAME ✓ Cell /—�llV//rf J PHONE / ExT. <br /> 009) <br /> �/L } <br /> HOME or MAILING ADDR�SS FAX# <br /> /Vi Alg, ( ) <br /> CITY l O STATE Cts 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: &&z2d rF& LZ k4 DATE: <br /> PROPERTY I BUSINESS OWNER9 OPERATOR/MANAGER [I OTHER AUTHORIZED AGENT [IIf APPLICAN 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 /> 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: - i' ECE IVSD <br /> COMMENTS: <br /> :• ; L 1 2017 <br /> SAN JOAQUiN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: L. 1_ <br /> ASSIGNED TO: I d EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: > PIE: 0 <br /> Fee Amount: Amount Paid 3 C7 ' © Payment Date q, -21 , I <br /> Payment Type C lcInvoice# Check# a 0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />