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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 I OPERATOR <br /> ( / (-2/w, CHECK If BILLINGAD0RE55O <br /> FACILITY NAME ,V ��/(lyl,// J <br /> Gi't �vu SE <br /> SITE ADDRESS dm/ — 2D � �J / G- 12r� J�7ZltilGTE3/ �S2/�j' <br /> �v Street umber Direction reef Name CI ZI Cade <br /> HOME or MAILING A RESS (If Different from Site Address) <br /> UStreet Number Sbeet Name <br /> CITY / ST w ZIP 2� <br /> PHONE#1 E- l#APN � LAND USE APPLICATION# <br /> X33 9G 6 <br /> PHONE 12 BOS DISTRICT LOCATION CODE <br /> PW 405 `�io7c <br /> EQ � CONTRACTOR/ SERVICE REQUESTOR <br /> R� OR G-'e J`� CHECK If BILLING ADDRESS <br /> BUSINES AME P E# EXT. <br /> Ho E Or M/A/ILING ADD 55 FAX# <br /> CITY ze7p/ <br /> T ZIP 2'9Z <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 beperformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,S rE a ERAL laws. �. <br /> APPLICANT'S SIGNATURE- DATE: <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not 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 It IS available and at the Same time It Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> APR 14 2016 <br /> InAnIHINCOUtATY <br /> ACCEPTED BY: EMPLOYEE#: ENVI N t <br /> IA <br /> AJ-41;il -PTMENT <br /> ASSIGNED TO: EMPLOYEE M h/ DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: /l yjl PIE: —I— <br /> Date <br /> Amount: O Amount Paid 3 t7 0 Q Payment Date <br /> Payment Type G� Invoice# Check# 1L a ' Received By. <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />