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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7Z(-16.,L- IJ euo SJz067V&?l <br /> OWNER/OPERATOR <br /> CHECK If BILLING A00RES5❑ <br /> FACILITYNAMEO,,,C <br /> SITEADDRES$ 76; , ! E- �jC�Nsf�k-T'97�✓/`�C'7 F/�1- -yGi4h/' q,S—Z�/ <br /> lao Street Number FDirection Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number street Name <br /> CITY STATE ZIP <br /> PHONE#1 E)rr. APN# LAND USE APPLICATION# <br /> aao ) J*-;' 2yoo 31a 1�3 PA- 1 5-w)-6& L$A <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> h C��.O�y `•��f-�����1��� CHECK If BILLING ADDRESS <br /> BUSINESS NAME V lei PHONE# ExT. <br /> 0'e y 7ioN <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY OCG` STATE CSW ZIP GlsZd <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 /> 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, Standards,SIATE and F ERAL laws. <br /> APPLICANT'S SIGNATURE: ® DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 19If APPLICANT IS not the BILLING PARTY proof of authorization t0 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: 1 it <br /> COMMENTS: OT� i- ptp{lw}a PAYMENTZe H e� <br /> At-&y <br /> RECEIVED <br /> APR 2 0 2016 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: '.\ EMPLOYEE 44EALTH DEPARTME DATE: <br /> I <br /> ASSIGNED TO: EMPLOYEE#: DATE: -oLo <br /> Date Service Completed (If already completed): SERVICE CODE: -;�:) P11: <br /> Fee Amount: Amount Paid 57C9C9 0 1 Payment Date Zv N <br /> Payment Type C(( Invoice# Check# SLI -7 ( Received By: 7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />