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SAN JOAQ UI C'i..LINTY ENVIRONMENTAL HEALTIMEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> OWNER f OPERATOR _�+ 1� <br /> GYVY\A(Y\ _C!X� CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ✓� (J <br /> treet Number D t'on o tred,�/'J' ��(('Q, 1 <br /> HOME or MAILING DDRESS (if Differe t from Site Address) <br /> S1 Street Number Street Name <br /> CITY c STATE 5 <br /> L <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> C-i(10 00 <br /> PHONE#2 19 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUEST CHECK if BILLING ADDRESS <br /> BUSINESS MEPHONE# EXT• <br /> v` �r� e a <br /> HOME or MAILING DRESS " � � FAx# <br /> CITY T E <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 DEPART11YMNt 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 thi ap ication and that the work to be performed will be done in accordance with all SAN JOAQuIN <br /> COUNTY(Ordinance Godes,Standards, T T and FEDF,RAi.;laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUstNESS OWNER OPERATOR/MANAGER [3 OTHER AUTHORIZED AGENT <br /> #'APpi-if��t, isnot the Bianyg PAR TF,proof of authorization to sign is required Title <br /> AUT14ORIZATION 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> MAR 17 2016 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE#: tJWT5" MENT <br /> ASSIGNED TO: te /e, M Gc�1�I w" EMPLOYEE M DATE. 311 /I(P <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: PIE: 4IQa <br /> Fee Amount: ��. Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 A SR FORM(Golden Rod) A. <br /> � . <br /> RE1/iSLip 11/17/2803 <br />