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y�I <br /> i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1m5 - L / t- <br /> OWNER/OPERATOR <br /> &Ll ( L <br /> K if BILLING ADDRESS <br /> FACILITY NAME <br /> rrlE G E <br /> SITEADORESSdsoo S f/oiL y DRIVE TYeAcy ?S-3 0-4 <br /> Street Number D11Ion Stree[Name CI Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Addrr�e�s^ns.T' <br /> G 1E L..�.� Street Number Street Name <br /> CITY STATE ZIP <br /> LA F errE G/� S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( -xs) (-03- 5775-e- 2 - o PA-1-7oo o <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DO CHECK If BILLING ADDRESS <br /> BUSINESS NAME C- PHONE# ExT. <br /> C E E oz- GS2 <br /> HOME or MAILING ADDRESS FAx <br /> • (.201) GL S <br /> CITU u dG� STATE ZIP 9saBi <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 ap b' at on and th t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S AT and FEDE laws. <br /> APPLICANT'S SIGNATURE: DATE:/ 4-1. 117 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR AMANAGEROTHER AUTHORIZED AGENT O4 <br /> If APPLICANT IS not the BILLING PARTY,proof of a horization 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 /> to 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 /> TYPE OF SERVICE REQUESTED: f Of rup LAN <br /> COMMENTS: <br /> ��� --„✓-„�� �ya�”� RECEIVED <br /> MAY 0 2 2017 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE M M%ff.H DE AR ME <br /> ASSIGNED TO: ( U EMPLOYEE#: DATE: , <br /> Date Service Completed (if already comp) ed): SERVICE CODE: SvZ� PI E: Q Z <br /> Fee Amount: �� Amount Paid (C Payment Date <br /> Payment Type, Invoice# Check# L/ -� Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />