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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /J�1 � iC e!+ A•Y.v CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 6�'kY - <br /> SITEADDRESS q 6 CCgC Y)�)� s TC U N <br /> Street Number Direction Street Name cityZi Ce <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> .2G- Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 5 to - 5 3 - jo a0l, o5s-&&v6l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) r(.`t r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE$TOR A'5k r a �� + .'A , e�� <br /> C' /r( W r"Y� CHECK if BILLING ADDRESS <br /> BUSINESS NAMEAsk '41." m4j�) ( Z# O � J; � <br /> HOME or MAILING ADDRESS �'1 FAX# <br /> CITY `�,v^✓v"i C �G3 STATE ZIP PJ L.)'5- ("— <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 /> 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 an DER <br /> APPLICANT'S SIGNATURE: DATE: 3 d <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MA AGER b OTHER AUTHORIZED AGENT ® Cnh1`fi�i�t(' /"��✓` <br /> I(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 to me Or <br /> my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Foocl -pIGc .1 C 1%U?C RECEIVED <br /> COMMENTS: <br /> MAR 0 7 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT, <br /> ACCEPTED BY: C` L1 EMPLOYEE#: DATE: 3>- 7- JY <br /> ASSIGNED T0: ' —7 1 �Z� EMPLOYEE#: DATE: -'._ v7 _ / <br /> Date Service Completed (if already completed): SERVICE CODE: J L PIE: <br /> / U <br /> Fee Amount: ! `' Amount Paid i{ Payment Date <br /> Payment Type Ji"; Invoice# Check# Received By: <br /> . 4� <br /> EHD 48-02-025 r, ) / SR FORM(Golden Rod) <br /> 07/17/08 /J'KG�� ,� ('Sy�'f <br />