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QJ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESTT# <br /> OWNER/OPERATOR <br /> �. `\, CHECK If BILLING ADDRESS E] <br /> FACILITY NAME K1 <br /> SITE ADDRESS Cir, e? G i <br /> I 9J 423 L E'/ffl OrC Z Jc <br /> Street Number Dlreclion Street Name�� CI Zi Code <br /> HOME Or MAILINGADDRESS (If Different from Site Address) <br /> e,-` Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> (tap -Ia 10b - �eo z <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) Z)(11 1 1 9c <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR� / CHECK If BILLING ADDRESS <br /> BUSINESS NA PHONE# E%T, <br /> rx —� / <br /> HOME rMAILINGADDRESS FAX# <br /> v cvi) 3S4 3 <br /> CITY Lob <br /> j STATE -4- 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, StaNrds, STATE and FEDERAL laws. n/ <br /> APPLICANT'S SIGNATURE: G/, I DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT 13i <br /> If APPLICANT IS n0 he BILLING PARTY,proof Of authorization to Sign IS required I 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 II is available and at the same time It Is provided t0 me Or <br /> my representative. ,At �I <br /> TYPE OF SERVICE REQUESTED: r�.�� �IC�— 4 )jl,(,� AC �, �('' �-�!! u <br /> COMMENTS: <br /> L?EpaC/ ?/' Z/I(-/ <br /> J'J; 0 b <br /> 2017 <br /> /'/ FFCcft/ � SAN JOAQUIN COU��!�/Tw b0 � VlONMNTqy � i0-o'r4)b <br /> ACCEPTED BYL (6 <br /> EMPLOYEE#: DATE: '� I i' T <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'z PIE. <br /> Fee Amount: tl Amount Pa I D Payment Date -716 <br /> Payment Type Invoice# Check# J/�O Rece ed By: <br /> EHD 48-02-025 l�/Lr=F�-� ` SR FORM(Golden Rad) <br /> 07/17/08 _ p T <br />