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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -reod 007L� 0 <br /> OVVNFR/PPERATOIZ 1 <br /> ,^`-�—J/ T bc f tl CHECK If BILLING ADDRESS <br /> F:,CII_ITY NAME y \1 ,�✓�`--S-- <br /> 1X/, rt �O� t <br /> SITE ADDRESS - �J�� �� - N �t <br /> oJ'cJr/`GI -Li r ` <br /> Stree[Number Direction Street Nam Zi Code <br /> HO t)I f`I I NG ADDRESS (If Different from Site Address) <br /> 1 Street Number Y K� Street Name <br /> CITY tfJGr;1 C L,k ' c1sa <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 9,01 <br /> PHONE#2 E^T• E OS DISTRICT LOC^.1!Or.! a'OnE <br /> CONTRACTOR/ SERN710E R.EQUESTOR <br /> 2EQUE 'OR <br /> 'T'V)r`� CHECK If EILLI!JG�D ARES:: <br /> BUSINESS NAME 11 1 - � � `T. <br /> HOME or MG DRESS- FAX# <br /> ILIN <br /> iA UA c ) <br /> CITY �/`�/Q 1 AT ZIP <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 laws. <br /> APPLICANT'S SIGNAT l,JRRZ--�\ DATE: :] <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT 9�4e BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, t, the owner ur operator -Ii the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or envlrunmental/si!.e 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. PAIT-1-W NAT <br /> TYPE OF SERVICE REQUESTED: V t� I(L1 � �,�r►hC�}I(� ar I� <br /> COMMENTS: [ ! <br /> JUL'2 6 2016 <br /> SAN JOAQUIN COU <br /> N <br /> HEALTH D- NTAL <br /> ACCEPTED BY: ftcf4(n <br /> EMPLOYEE S CV DATE: 70-01V 0-01 <br /> ASSIGNED TO: a EMPLOYEE#: DATE: 7 t.2 <br /> r(l�ln <br /> Date Service Completed (ifalready completed): SERVICE CODE: P/E:: <br /> Fee Amount: (✓ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />