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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ���b g67(o5,,�2,y <br /> OWNER/OPERATOR <br /> _ CHECK If BILLING ADDRESS <br /> E C v H Q'--4,C-4 <br /> FACILITY NAME <br /> SITE ADDRESS T <br /> Street Number D ction Street Name - city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ^ Sn 1 ZIP �I� <br /> PHONE#11 `/ ` EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> c <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> _— ' CHECK if BILLING ADDRESS <br /> � U r - G ��Q�cI ~- <br /> BUSINESS NAME PHONE# EXT. <br /> 0 A J& V1C U — o� � <br /> HOME or MAILING ADDRESS FAX# <br /> !' A V -7— ( ) <br /> CITY 4 T STATE C ZIP <br /> 4 9 <br /> BILLING A/CKNOWLEDGEMENT: 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: —y� T� U. �?Cys"�,u } I(L DATE: / ZZ <br /> PROPERTY I BUSINESS OWNER EL OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ / <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 /> t0 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: F CSC Y` 1<; L I I L <br /> COMMENTS: PAVIWEN` <br /> lel x°1 RECrEivEr) <br /> DEC 3 0 2016 <br /> SAN dOAQUIN <br /> ACCEPTED BY: EMPLOYEE#: NAL I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: i_ PIE: <br /> / <br /> Fee Amount: r Amount Paid 13� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />