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SAN JOAQUTAUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> service- s4-4--h o rl $©67 <br /> OWNER/OPERATOR <br /> be b,b/6 J'U.- l/�I <br /> eL- CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> '1-racy 'Tra-c lC Cin c� Arc f-"a <br /> SITE ADDRESS -3c,40 Af , et C�% <br /> Street Number Direction / Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#f EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ea-Jh lee a Ale nSGLCC GAJ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESSFAX# <br /> i ( IZs) 4&'-;) -�3 <br /> CITY Piero STATE e A- 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 <br /> or 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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � L-1� DATE-: <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LJ ce,-I 1-ra—r I fl r <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: !�S i (�%/'cp V REC <br /> COMMENTS: FEO' 2 5 2015 <br /> SANEJOAQUIN RO �y <br /> 11EgiLTH DE qq AE <br /> �,T A N, <br /> ACCEPTED BY: r`7J(1"r'�� EMPLOYEE#: O� DATE: 23 t s— <br /> ASSIGNED TO _f EMPLOYEE#: DATE: <br /> -2-12-3 <br /> Date Service Completed walready completed): SERVICE CODE: j f P I E: 3O47' <br /> Fee Amount: Amount Paiar 3q0, 6-D Payment Date o2 ls— <br /> Payment Type ✓ Invoice# Check# ,Z?,E) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />