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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/OPERATOR <br /> BILLING ADDRESS <br /> i <br /> �J CiNv6c dl2LA&Ih ANOMJ�0QNIVF— omCHCKIf <br /> FACILITY NAME <br /> SITE ADDRESS -32 <br /> Z S 1,At/ R OA ) <br /> Street Number Direction S(r "t Name Y City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAM r Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> X09 ) 3107 - 2a 53 70 -.5-W PA -X300-7 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , / CHECK If BILLING ADDRESS E] <br /> BUSINESS NAMEn PHONE# EXT <br /> 4� e.4 AIF-7'K efiAll a Z 226& dM o <br /> HOME Or MAILING ADDRESS FAX# <br /> D . Sox 3 (2o ) 66g-25W <br /> CITY u Lc� STATE /1/� ZIP 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 ENVTRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards, ST nd FEDE ws. <br /> APPLICANT'S SIGNATURE: DATE: j 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT M <br /> IfAPPLICANT-is not the BILLiNGPARTY proof of authorization to sign is required Tate <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: N1T C GO SEP L W7-gfrV U (Y!E <br /> COMMENTS: f rATMENT <br /> 5/b/i`(1 5/«���,6/�i�� RECEIVED J c� <br /> t q--r <br /> Al'�� 0 7. 2014 �o,r►�, <br /> SAN JOAQUIN COUNTY <br /> IaNVIRAMIENTAL <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: j' Lvk k EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: p� <br /> Fee Amount: Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />