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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH U`EPARTMENT <br /> SERVICE REQUEST <br /> rnnll IT\/111 Jl <br /> Ty e o Business or Property SERVICE REQUEST# <br /> O7R/ PERAT R <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME ,c2 <br /> SITE ADDRESS t ra 1�(-/ /�,IV"` [7%SZ S <br /> GI iii L� Street Number Direction ,l L` Street ame �'CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number �) Street Name <br /> CITY , Ai STATE ZIP (,5 Z C <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> /- `n <br /> (2c�) S �` 5 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> (mac) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> >a J 1 r M CHECK If BILLING ADDRESS <br /> BUSINESS NAME �C (�© Y--i--(T /12 <br /> ( G/1 2 J <br /> PHONE# �XT' <br /> G � <br /> HOME or MAILING ADDRESS` FAX# <br /> —4 C)Se St ( ) <br /> CITY I „ STATE C,A ZIP q! Z 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 /> 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l<LL-l0�f o L�� V�1 S [J - 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, 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. \ n <br /> TYPE OF SERVICE REQUESTED: V l'6 b e o� Colv t1t PAYMENT <br /> COMMENTS: RECDIVED <br /> MAR 1 1 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: G� EMPLOYEE#: DATE: 7 1 <br /> ASSIGNED TO: �CL �]{ C EMPLOYEE#: DATE: I.2- <br /> Date Service Completed (if already completed): SERVICE CODE: s LU PIE: 1 t) <br /> Fee Amount: 11�(,' Amount Paid �. ,�?�� , Payment Date <br /> Payment Typ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />