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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gco o ���( <br /> OWNER/OPE OR <br /> S�VlC.3�-'-+r'' 4 <br /> 'f'�Vl. <br /> � CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS V( <br /> Ze)SL StreetNuni:,er I Drection 1� trk amt `—^ ' �� Code , <br /> J <br /> HOME or MAILING ADDRESS df Different from Site Address) t I Val VKP_� arc <br /> Street Number I 1 Street Name <br /> CIT-Yr ST4T LIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (16 1) Z10 <br /> PHONE#2 EXT• BCIS DIS",:ZT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE )R-QiUESTOR <br /> REQUESTOR 5 CHECK If BILLING ADDRESS® <br /> BUSINESS NAME I V ia1 PHONE# EXT. <br /> 7 Ct <br /> HOME or MAILINt:QnnvcccFAX Ii <br /> �2 I m✓Y?E�iV CA-64e, ( ) <br /> CITY STATE cA 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 I BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> I lTHOIN!Tw !-will O RELEASE <br /> ur-r�u M": nr�, <br /> AV IrIV RILMIIVIY I V RCL.CAJC INrVRMAl1VIV. VVhCII applicable, 1, the Owil@F or operator of file property located it the auUVt; <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. PAYMENT <br /> ry ^/, <br /> TYPE OF SERVICE REQUESTED: VD-od �?Vu _l l/f c�/ "�'�� 1 <br /> COMMENTS: <br /> JAN2 8 2016 <br /> SAN JOAOIJIN COUN <br /> ENVIROMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: IV�G�i^ EMPLOYEE#: DATE: <br /> Date SeRrice Completed (if already completes!)_: f SCRVIL­CODs: - 7 PIE: <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 />