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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �)g 067�5) � <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME S m60 I cc.kes <br /> ;ITE AD"DDRESS \4J . CP 'O r.y Imo. Sw;4e. 110 <br /> Street Nomber Dlrectlon Street Name 1 <br /> CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ``DW <br /> MStreet Number Street Name <br /> CIN STATE ZIP <br /> R, � c� 9s3�� <br /> PHONE#1 EXT. APN# + r- LAND USE APPLICATION# <br /> (2ai) 4'�`16--O 1 q'7 (Q I U© �� <br /> PHONE#2 Exr. BOS DISTRICT LOCAT N CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> CHECK If BILLING ADDRESSO <br /> BUSINESS NAME PHON / �r ExT. <br /> MMV G 53 <br /> HOME or MAILING AADRESS JL— FA%# <br /> CITY STATE ZIP A-7 (e <br /> BILLING ACKNOWLEDGEMENT: I, the undersigneproperty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIROf ENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified o this form. <br /> also certify that I have prepared this application and at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards S AT a d FERE A WS. t G <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATYR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY,Proof of authorization to Sign is required Titre <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 sajjf�g�li�j�[q ed to me or <br /> � <br /> my representative. A MEN <br /> TYPE OF SERVICE REQUESTED: Rod7 /a , <br /> COMMENTS: DEC 19 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 10z ./q_ 17 <br /> ASSIGNED TO:a Qa 'Q EMPLOYEE#: DATE: /� ,// / 7 <br /> Date Service Completed (if already completed): SERVICECODE: 3 PIE: <br /> Fee Amount: Amount Paid - — Payment Date a G , <br /> Payment Type C Invoice# Check# 3 © Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />