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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH br-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> c�`Y\/ , 1�C� CHECK if BILLING ADDRESS <br /> FACILITY NAME C\ <br /> SITE ADDRESS <br /> <C't <br /> Street Number I Direction Street Name Ct Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Addre s) /l�{ <br /> 3 1 Street Number I l/ �Y Street Name <br /> CITY <br /> GVl Y-\ �� �S sME <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Y (CA (Se-r0 r)� ��VeS Q a CHECK If BILLING ADDRESS <br /> Exr, <br /> BUSINESS NAME Lo' � P �# 33 '1-Cosi Ccs <br /> HOME Or MAILfNt�DDCESS�n I � Y SNc�,x�� (Ax# ) <br /> CITY \Ci U ��/l� ��U J� STATE 1 ZIP 9";-39- <br /> BILLING <br /> ";-39BILLING 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, Standardl,ST TE and FEDERAL IPWSyy '7 l <br /> APPLICANT'S SIGNATURE: �/ A( ?� DATE: <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, 1, 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 130IM"to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: — I L C tTf C•/'t <br /> COMMENTS: MAH It 2017 <br /> SAN JOAQUIN COUNTY <br /> /l ENVIRONMENTAL <br /> -7M <br /> 1 y -7 v HEALTH DEPARTMENT <br /> ACCEPTED BY: \"� EMPLOYEE#: DATE: ]� I ', / 7 <br /> ASSIGNED TO: � EMPLOYEE#: DATE: ? 7 7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ZC u- Amount Paid 3 c7 m Payment Date 3 , j 7 17 <br /> Payment Type C t Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />