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SAN JOAwUIN COUNTY ENVIRONMENTAL HEALTh DErARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FooD <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> aru Iry NAu <br /> I <br /> SITE ADDRESS14 Q C ��Q <br /> /� / o <br /> ll Street Number D Street Name I Zi Code <br /> HOME or MAILIN ADDRESS (If Different from Site Address) <br /> ! L2 0 Street Number Street Name <br /> CITY STATE ZIP <br /> HONE#1 EXT. APN# LAND USE APPLICATION# <br /> ) - - -) l �91133--?-7 <br /> PHONE#2 ExT• BOS DISTRICTLOCATIT N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J CHECK if BILLING ADDRESS <br /> B SINESSNAME « PHONE# EXT, <br /> r `! <br /> HOME or MAILING ADDRESS . FAX# <br /> IS t ( ) <br /> CITY tL ✓� STATE cliq ZIP <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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: SCJ206TH/ DATE:�r <br /> PROPERTY/BUSINESS OWNER Rf OPERATOR/MANAGER El OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to 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 /> WMENT <br /> TYPE OF SERVICE REQUESTED: O -c bar) <br /> COMMENTS: I RECEIVED <br /> C YIu ►��.e. <br /> C41 c uoncy— FEB 0 6 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ';� , - ) <br /> ASSIGNED TO: C_ /t EMPLOYEE M DATE: --5. <br /> Date Service Completed If already Completed): SERVICE CODE: U b/ P 1 E: <br /> Fee Amount: �`�� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />