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SAN JOAQ_ COUNTY ENVIRONMENTAL HEALTH —,iPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR / / <br /> lQ CHECK If BILLING ADDRESS <br /> 13 <br /> FACILITY NAME <br /> SITE`ADDRESS (w' p J n A� ,c <br /> J W el N�ber I t n r lSthreet R[jame 29 Cod <br /> HOME OI MAILING ADDRESS (If Different from Site Address) t _ �� <br /> Street Number A Nz <br /> e <br /> CITY STATE zip NOV 17 2011 <br /> PRONE#1 Exr• APN# LAND USE APPLICATION# <br /> (Zqp ) 5-?-7- 6COO 1 - -I I FRITT <br /> �VI� T <br /> PHONE y2 P7C7. [�-9 DISTRICT LOCATION CODE <br /> ) <br /> COI` MACTOR/ SERVICE, REQUESTOR <br /> REQUESTOR <br /> C S-trul C& wU'o—j CHECK if BILLING,ADDRESS <br /> BUSINESS NAME ( P E# Exr, <br /> C SC/v�"C _ 7 0 <br /> HOME Or MAILING KESS ] /' FA <br /> 7L <br /> CITY O STATE f x ' zip -7 7ZZ, <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 /> 1 also certify that I have prepared this application and that the work to xilperformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA �EDERALs- <br /> APPLICANT'S SIGNATURE: DATE: to .Z 1 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT —'Q � <br /> If APPLICANT is not the B& MG PARS proof of authorization to sign is requlre Title <br /> AUTHORIZATION TO RELE=ASE 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 /> t0 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: �/ ��. VED <br /> 0 C T 2 8 2015 <br /> SAN JOAQUIN COUNTY Co <br /> ENVtROMENTAL <br /> 1JEALTH DEPARTMENT C <br /> ACCEPTED BY: EMPLOYEE : DATE: <br /> ASSIGNED TO: / yft EMPLOYEE#; DATE: <br /> Date Service Completed (ifalready Completed): SERVICE CODE: t PIE: �✓ <br /> Fee Amount: C>j) Amount Paid 3,?O CC Payment Date �v <br /> Payment Type Invotce# Check# G Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />