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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 ,1 <br /> ►y����y A - C^A� CHECK IF BILLING ADDRESS� <br /> �� <br /> FACILITY NAME <br /> LA cnESa <br /> SITE ADDRESS <br /> Street N;imber Direction 1 Zr4'ti Ke'��` ' C- v` c1t <br /> IOME Or MAILING ADDRE'S'S (if Different from Site Address) <br /> l� `A K CV—Z W K IZ- Street NumberT Street Name <br /> CITY STATE ZIP <br /> -x-001 tJ c A - I <br /> PHONE#1 ExT. APN# LAND USF APPLICATION# <br /> (510) a-s a-c�c� 1 _ <br /> PHONE#2 EXT. BOS DISTRIC' LOCATION CODE <br /> CONTRACTOR SERVICE IZEQUESTOR <br /> REQUESTOR <br /> ��Qw, (1 - ���� ,u CHECK If BILLING ADDRESS <br /> ,tel C 1 <br /> BUSINESS NAME �n E� � PHONE# EXT. <br /> ri ( ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY t5TO Qt` CR G1S';L(0q STATE ZIP <br /> BILLING AGKNOWLECGE10ENT: 1, 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 A77sapplicati <br /> identified on this form. <br /> I also certify that I have prepare n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Sta ards, STATE a d FEDERAL laws. <br /> APPLICANT'S SIGNAT U E: DATE: (/ <br /> PROPERTY I BUSINESS OWNE ❑ OPE .ATOR/MANA OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT l thB A ,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 /> 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 /> MENT <br /> 1 <br /> bud <br /> ��q IG —� <br /> VDE nr SERVICE REQUESTED: �G u d 0't I "� C 1 <br /> COMMENTS: <br /> AUG 0 2 2016 <br /> SAN JOA0UIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /� O EMPLOYEE#: DATE: <br /> r Z I� <br /> ASSIGNED TO: \ G "l e V 7 01 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE(-ODI.: ,(� i,3-j P 1 EI: I I iv <br /> Fee Amount: I Amount Paid Payment Date <br /> Payment Type v Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />