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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property t �,1FACILITY ID# SERVICE REQUEST# <br /> C baa eJ C4:CL� l$1 u P� :>f,'. -7 5i'`6,�-' <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L\AY VY K"A J RP.S� ✓QAA <br /> SITE ADDRESS q 6c R Rpj yiaL RUN (� � �q IAA. J ld P <br /> Street Number DirecS tion �f Street Name CI ZI Caltle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �Jy) Q <br /> 2 G • _ Street Number " - /r-4,JShet Name61 Vr/ <br /> CITY STATE ZIP <br /> LLv�KA 0 y"? C A <br /> PHONE#1 EaT. APN# LAND USE APPLICATION# <br /> I ) slo 57 3- 5 05 ul 6`��s&loo01 <br /> PHONE#2 E%T. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORAJV/Y lLr AI d I� / CHECK If BILLING ADDRESS <br /> BUSINESS NAME A'sk Ala w • ,nL-C4 PHci bi n -Z E^ <br /> HOME or MAILING ADDRESS I �+ FAX# <br /> Z J <br /> Cr Ar(N c't L� �J1 ✓� ( ) <br /> CITY _ L\v4v (Z_A STATE Zip y y s s <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, STATEan DER eww�. <br /> APPLICANT'S SIGNATURE: DATE: -14 <br /> PROPERTY/BUSINESS OWNER OPE TORIM AGER OTHER AUTHORIZED AGENT <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization t0 sign IS required Tirle <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. <br /> RAYMENT <br /> TYPE OF SERVICE REQUESTED: FPlop t'lG p 1 C j L1 c RECEMD <br /> COMMENTS: <br /> MAR 0 7 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT, <br /> ACCEPTED BY: �.>,pr1 EMPLOYEE#: DATE: 25_ -7 / <br /> ASSIGNED TO:" -A U Z— EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J L P/E: U <br /> Fee Amount: Amount Paid 6' Payment Date 3 - 7 - <br /> Payment Type C` �. Invoice# Check# Received By:' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />