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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / <br /> / (41's <br /> / f I I ! CHECK If BILLING ADDRESS <br /> FACILITY NAME lij � ` (.(�/ <br /> SITE ADDRESS + y� i —y <br /> Street Number Uir�n Ci) 1� Foy' I I Sfr�et Name t Ci Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2 w t r o W u:h Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> L 0r� o i i C <br /> HOME or MAILING ADDRESS, <br /> S U11 (Son W(IV R1T ( ) <br /> CITY I( STATE ZIP 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 /> 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: xm DAAT�� N—Oy — <br /> PROPERTY I BUSINESS OWNER E5-�OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> It 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: C .rJ/ U CA-e T—VIC G <br /> COMMENTS: <br /> RECEIVED <br /> APR 0'4 2016 <br /> SAN JOAOUIN COUNTY <br /> IENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE M ATE: (� <br /> ASSIGNED TO: �:�1 > tJ✓1 ,^u� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): " SERVICE CODE: V P 1 F: <br /> Fee Amount: I��0 W Amount Paid t3 d (� U Payment Date v q <br /> i <br /> Payment Type Invoice# Check# Received By:Z <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />