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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pro rt FACILITY ID# SERVICE REQUEST If <br /> �� ,yCoo '73136o, <br /> OWNER/OPERATO14 <br /> GAo NAME <br /> �' _ I- \ CHECK If BILLING ADDRESS <br /> � r vt y/� <br /> SITE ADD r58 OQ -Yl , /V0�1l� Al <br /> i l•L� L I !S Z <br /> T rtreet Number Dreclion /V S[reet Name CI Zip Code <br /> HOME Or MAH Nr A•.ii ECC !I{DiffeUt from Site Address/1y, <br /> O9'6(y 7/�// �� Ab Street Number Street Name <br /> CITYD/ STATE Z <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# i <br /> PHONE#2 ExT' BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <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, Standar TATE nFEDERAL law .- <br /> APPLICANT'S SIGNATOR D"t q /15 <br /> PROPERTY/BUSINESS OWNER 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, 1, 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 I is available and at the same time it is provided t0 me or <br /> my representative. ✓ I, 5 - �,F <br /> TYPE OF SERVICE REQDEB TED: <br /> COMMENTS: r / I <br /> .111 i�rGv�Z 1& C's V"-y <br /> 9 2 <br /> ACCEPTED BY: c G- it-6e EMPLOYEE#: DATE: <br /> ASSIGNED TO: i S(A�li(� EMPLOYEE#: DATE: <br /> Late Service Completed (if already completed): SERVICECOOE: O/ I PIE: RZ <br /> Fee Amount: I -gyp Amount Paid ACA) ,�� Payment Date <br /> Payment Type �7 Invoice# Check# S - AVUrNt Received By: <br /> RECEIVED <br /> EHD 48-02-025 SEP 14 2015 SR FORM(Golden Rod) <br /> 07/77/08 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br />