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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#, SERVICE REQUEST# <br /> Sr�li07 L�1-)(6 D <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME rte; , M1 n� 67 0 <br /> SITE ADDRESS7"e"..] S:lStreet NumberStwr Nam. IU C KCit%N r J <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY_ STATE ZIP q <br /> f-OCx— t `�/ CA CS 2dS� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> cYQ� ?Ctr- o q-7 (o <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> AA Ile c- '-I/ 4 13 �-�� S CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> IqN 4io P/ - X97 (0 <br /> HOME or MAILING ADDRESS FAX# <br /> � C-A <br /> CITY <; � C/L�/\J STATE G� ZIP / Tz U )j <br /> BILLING/ACKNOWLEDGEMENT: 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 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 I S. <br /> APPLICANT'S SIGNATURE: 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 /> 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: V a I v -e I v U d M( [ahbn PAYMENT <br /> COMMENTS: <br /> AUG 2 4 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: / O//1qn c EMPLOYEE#: DATE: ` 2 LI / <br /> ASSIGNED TO: C �/1 1 x`11 1 ' EMPLOYEE#: DATE: V �—.I /'^V <br /> Date Service Completed (if already completed): SERVICE CODE: SC U/n' p I E: �13 <br /> Fee Amount: ' 1 Amount Paid 13 Payment Date 2�� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />