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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ES� <br /> ERVICE REQUEST# <br /> o-73ggq <br /> OWNER/OPERATOR C {P-Dnp, f-C VGI 1de, CHECK If BILLING ADDRESS <br /> FAciiTv NAME p'rrr' <br /> SITE ADDRESS ZZOEiC �. <br /> Street Number Direction Street Name Ce ZI Code <br /> 1 bMF 01 MAILING ADLRESS (If Different from Site Address) 27 k/r 121)-40 <br /> Street Number Street Name <br /> CITY GSCAW J STATE CA ZIP �' 37-0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 16 20) 9 -IlIr- 24�' Zdo- °/q 4 16 -ILD -_ <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A r f w- <br /> r", CHECK If BILLING ADDRESS <br /> BUSINESS NAME ht- N �(./(��{J.� PH�T# 3 7 V-64/ 3 ExT. <br /> HOME Or M.AILINL ADDRESS O f�J / FAX# <br /> P ( ten 37y- 072 3 <br /> CITY STATE /4 ZIP A' lam. <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> also certify that I have prepared this application and that the work to be performed will be done in accomance 1h all * A JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE I laws. <br /> r <br /> APPLICANT'S SIGNATURE: DATE: /2' L�� <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ '• <br /> Il'APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE "IFORMATION: When applicable, I, the owner or operator of the property local -d at the Jove <br /> site address, hereby authorize the release of any and all results, geotechnical data andlor environmental/site assessn=nt information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It .s available and at the same time it is pi /ided to Ine or <br /> my representative. <br /> TYPE OF SERVICE R.QUESTED: ,/�"r MCej T <br /> CO.,MLN'r- _ PAYMENT <br /> P/lz//6 RECEIVEC� <br /> p, lW W I <br /> DEC`2 S 2015 <br /> SAN JOAQUIN COU 11TY <br /> ACCE TED BY: EMPLOYEE#: DATE: ANT <br /> AL <br /> HEAI,Tfi DEPARTM Ni <br /> ASSIGNED TO:ere- p EMPLOYEE#: DATE: E l7/ <br /> Date Servicc'S,,mplpted (if already completed): SERVICE CODE: PIE: ! J <br /> Fee Amount: •' -� Amount Paid U U Payment Date <br /> Payment Type�, C Invoice# Check# 6 a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />