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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/OPERATOR1 ` prl <br /> S0.l e �Q 1 L I ( 1 1 a CHECK if BALING ADDRESS <br /> FACILITY NAME L1 jz- ,/� L <br /> SITE ADDRESS 17 <br /> 5O � ( �� C /� •,tzd+�(�me S1— <br /> �`rU C tT N CI.S Z 0 e, <br /> Street Number Direction J` Street Nacity Zip Code .. <br /> I HOME Or MAILING ADDRESS (if Different from Site Address) <br /> 3 W Street Number Street Name <br /> CITY ( A- ` STATE ZIP <br /> J ` ®�--- (I Y) 9 S Z 0 <br /> PHONE#1 EXT. APN# I LAND USE APPLICATION# <br /> PHONE#2 EXT. tiOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTR,kCTOR/ SERVICE REQUESTOR <br /> REQUESTOR L \ t V \ 2- CHECK If BILLING ADDRESSO <br /> BUSINESS NAME r-- L L 'l `� 1/`1� ,^ ) PHONE# EXT. <br /> L l� 1 V l�F"-C l_ (Z6-1) () - 2 <br /> HOME or MAILING ADDRESS FAX# <br /> 3 iP w ( ) <br /> CITY �y� O 0 c /�\ STATE 0 Jam- ZIP C/ S Z-C) <br /> BIL=LING ACKNOWLEDGErOENT: E, 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: �u-e— V Lok c�7-, 6-12- � DATE' �' -Z <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 /> 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: yl � p 1 U/� L PA <br /> ift <br /> COMMENTS: <br /> ,Q` n`U��' JUL 2 2 2016 <br /> SAN•j0p0UIN COU14ry <br /> ENTAL. <br /> EN\1IROM <br /> HEATH DEPARTMENT <br /> ACCEPTED BY: rZi EMPLOYEE#: DATE: "-7 as- <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E: I <br /> Fee Amount: _�jAmount Paid Payment Date 7( a 6 <br /> Payment Type 0 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />