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SAN JOAQUOICOUNTY ENVIRONMENTAL HEALTH Gt_F-ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N SRoo7z27 <br /> OWNER/OPERATOR <br /> t � CHECK If BILLING ADDRESS El <br /> Q- Ctr <br /> FACILI NAME � 7 <br /> t �S' � Q 1 G� <br /> SITE ADDRESS <br /> ,Q recon ,. /+ 1c�/ , <br /> F d Street Number D iY Q Atreet Name �4o `Gifu-+o r\ Zi.Cn <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 'l V'e— Street Number c, Street Name <br /> (I STATE ZIP <br /> 62 9S L ti <br /> PHONE#1 EXT. APN# LAN^11,E APPLICATION# <br /> (" cyf) — AUC) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE. <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> `'CA <1k 1 _j _� c, r CHECY.IfBILLINGADDRESS® <br /> BU NESS NAME PHONE T l� / PHONE# /ryy �( EXT. <br /> t' - C.? 1 Cc �t C> <br /> HOME Or MAILING ADDRESS FAX# <br /> CITI K j l ` _ $CTATE ZIP <br /> T(J C <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: !tjn - A L'-- .L-rc3n t>c_ DATE:21(9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �O� Y21(��� cr. ��/� RECEIVE,) <br /> COMMENTS: FEB 18 2016 <br /> LqywoNV.EKTAL <br /> HMTH DEPARTMiNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: v)(2 ����a�eS EMPLOYEE M DATE: z 18 J I <br /> Date Service Completed (if already completed): SERVICE CODE: b� PIE: I <br /> Fee Amount: l Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />