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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> (St- q1-17 <br /> 4�rI� CHECK if BILLING ADDRESS <br /> FACILITY NAME �L L`C3 <br /> SITE ADDRESS /i//�K'T//t/ L�7/JAY �C I dl� ✓� OG/� �L�� <br /> Street Number Direction Street Name C Ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /1 (/ <br /> -,L/�Street Number Street Name <br /> CITY n STATE ZIP �� 7 <br /> L <: ES (f/q <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( )6,;T 39 5-- 'y ye <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � 7 CHECK if BILLING ADDRESS <br /> ( <br /> 1,2 <br /> BUSINESS NAME PHONE# EXT.� <br /> ei 7 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY ( L• &/cC 5- <br /> $TATE �` ZIP - j -, <br /> BILLING I_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 /> 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: .7 ��/ /,�CS <br /> PROPERTY I BUSINESS OWNER 04RATOR I 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: <br /> COMMENTS: On <br /> o �11`lV.to <br /> jyi 2017 <br /> SAN JOAQWN COUNTY <br /> ENVIRC)t4 1ENTAL <br /> ACCEPTED BY: t i�� cp EMPLOYEE#: DATE: - _ . 7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> 9 <br /> Date Service Completed'(if already completed): SERVICE CODE: I 'j P I E: /!I <br /> Fee Amount: y );� . co Amount Paid Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />