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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /DE L_ sRc�7472-1 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> el'e4-A <br /> FACILITY NAME <br /> SIRIA ea-AVEAJX <br /> /} _ <br /> SITEADDRESS ersj W L/NvE TRAM/ 7130 <br /> Street Number Direction Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3.2S f;L />7 OA/TE,2E y <br /> Street Number /Street Name 9 /� <br /> CITY f nL SeATATE ZIP / *s-t% <br /> PHONE#1 ,961 L' Ext. APN# LAND USE APPLICATION# <br /> 610fl 93S--,P21-79; S-090 -.z 3 P -Z&000D4 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR DvAi <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME E PHONE# ExT. <br /> 02— G L <br /> HOME or MAILING ADDRESS FAX It <br /> 0 —.25 IB <br /> CITY L STATEGr,4 ZIP S-3 Q, <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 1 have prepared this 1 ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards AT and FaEDL Ws. 1 <br /> APPLICANT'S SIGNATURE: DATE: �— <br /> PROPERTY/BUSINESS OWNER El OPERATOR/ ANAGER ❑ HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of auth nation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applic le, 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 m Of <br /> my representative. o <br /> TYPE OF SERVICE REQUESTED: Q . k A PAYMENT <br /> COMMENTS: RECEIVED APR <br /> A/tA <br /> �,,,� P�r✓U APR-2 5 2016 ENVIRONMENT HEALT <br /> SAN JOAQUIN COUNTVPERMIT/SERVICES <br /> ENVIROME14TAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 9• aS/)(� <br /> ASSIGNED TO: Tgs�p Q� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S�JC2?� PIE: 2100 <br /> Fee Amount: 2(;0•6p Amount Paid 6 C2p L) Payment Date L/ ' S' <br /> Payment Type G- :_ Invoice# Check# 3 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />