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SAN JOAQLrtN COUNTY ENVIRONMENTAL HEALTH VcPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 573-7,J( <br /> OWNER/OPERATOR <br /> ,�n Ck C 1 ; CHECK If BILLING ADDRESS <br /> e CA <br /> FACILITY NAME p`�\� <br /> SITE ADDRESS 2u�© �ryy J� A <br /> Street Number Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) i♦— s� N\2\� c) C OJ r-� <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> \ � -1S —7b <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# , <br /> ( ' °531- 0--7 uS <br /> PHONE#2 EXT. BCIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR h a et <br /> n n l CHECK If BILLING ADDRESS <br /> BUSINESS NAME �� �-C PHONE# � � �� ExT. <br /> HOME Or MAING ADDRE S (:4FAX# <br /> ( ) <br /> CITY TATE ZIP J <br /> BILLING ACKNOW EDGEMENT: 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 associatP,d with this project or <br /> activity will ba 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 7 <br /> DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; �2 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AuTR6RIZED 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 /> TYPE OF SERVICE REQUESTED: -�� _ CAL <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> DEC 0 3 2015 <br /> SAN JOAQUIN CO <br /> ACCEPTED BY: c EMPLOYdML IV, <br /> p�R rAL DATE: r <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 J �'-- <br /> Date Service Completed (if already completed): SERVICE CODE: SGJV P I <br /> Fee Amount: S 30 Amount Paid..j' �b fJ�� Payment Date t <br /> Payment Type J?�( a Invoice# Check# Received By: <br /> EHD 48-02-025 1 N�►Z e�-E��c. Pc1r� . <br /> SR FORM(Golden Rod) <br /> 07/17/08 �[ � C ^ <br /> r� c152os <br /> 3aA-\ re, <br />