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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> n(C) RUD-7te <br /> OWNER/OPERATOR �bmolSE]CHECK If BILLING ADDRESS <br /> FACILITY NAME Loc,c, <br /> SITE ADDRESS ,2q -� C lAn Y r `C \fV �� S C l�Z j <br /> Street Number Direction reef Name city ode <br /> HOME Or MAILING ADDRESS (if Different from Site Address)/T ZL' ^ ( 1 f M <br /> Street Number I " Street Name <br /> CITY :\ ST/A! ZIP <br /> PHONE#1 lJL Y ExT• APN# (LAND7 \USE APPLICATION# <br /> � (2 CPQ-315 <br /> \ PHONE#ZT• BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C �` �� CHECK if BILLING ADDRESS <br /> BUSINESS NAME �YQS j YYY�C�,n O PHONE ���� _�jC �XI <br /> HOME or MAILING ADDRESS C1 ` I I,1 m S+ FAX# <br /> z� N .� ( ) <br /> CITY c � STATE ZIP <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: 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. FWMENT <br /> TYPE OF SERVICE REQUESTED: tooda( Tjisp&Mn <br /> COMMENTS: <br /> N& owyto- a nS lelfth-0n DEC 19 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ffr9e1aVVVV���`A t l F Vt " EMPLOYEE#: DATE: 1;- Iq P <br /> ASSIGNED TO: F EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: V PIE: in 3 <br /> Fee Amount: OI Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By:-7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />