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0 1* <br />HEcava-, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST SEP 2 8 2015 <br />Type of Business or Property <br />BUSINESS NAME 'iL y 1 ✓ � ti,E'* <br />�-(7/(4;-71-` <br />FACILITY ID # S <br />HOME or MAILING ADDRESS �! fT, _ %) <br />^� <br />L <br />G � <br />"/ <br />CITY ` C y STATE �.. ZIP <br />©0 Q <br />wu 3 Z <br />OWNER /OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS V v <br />et Number <br />y <br />it I n V � ��tr <br />t Name <br />� � <br />DATE: <br />I <br />HOME or Maim ADDRESS (If Different from Site Address) <br />EMPLOYEE M <br />CITY <br />—TPN <br />Street Number Stmt Name <br />STATE Zip <br />Date Service Completed (if already completed): <br />PHONE#i Ext. <br /># <br />LAND USE APPLICATION # <br />Fee Amount: <br />PHONE #Z Ext. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SF,RVIC V.. Rlfi'.n1T11?RTnV <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 'iL y 1 ✓ � ti,E'* <br />�-(7/(4;-71-` <br />PHONE # <br />�2�`�L) <br />HOME or MAILING ADDRESS �! fT, _ %) <br />^� <br />L <br />FAX # <br />( ) <br />CITY ` C y 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 pr0)ect 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 applicati n d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE EDERAL IeWS. / <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY i BUSINESS OWNER 13PERATO i M AGER ❑ OTHER AUTHORIZED AGENT w IIIA 4' 0A+7L q --K-- <br />If APPLICANT is not the BILLING PARTY proof Of authorization to sign is required Ti rl e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />t0 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 />� 7 <br />��j'y� <br />�'4 yM <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />2� I <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />tJr{ 2!1 <br />7� <br />Date Service Completed (if already completed): <br />SERVICE CODE: SG <br />PIE: <br />Fee Amount: <br />Q;.( <br />Amount Pai 3,70, o D <br />Payment Date <br />Payment Type <br />Invoice # <br />C ck # /g/4h� <br />Received By: <br />9gra65 <br />EHD 48-02-025 <br />07/17108 SR FORM (Golden Rod) <br />