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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH9PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Yuiuo ]-� f'DUAP Sip b ��klo <br /> OWNER I OPERATOR ` <br /> CHECK If BILLING ADDRESS <br /> & r �� ' <br /> FACILITY NAME <br /> SITE ADDRESSvver c <br /> t2- w St et Numbe Direction _ Street Name �J / JCi 7Zi Code <br /> HOME or MAILING ADDRESS Diffe/reent from lit <br /> Ae <br /> �Addn:ss) <br /> 0 Ll, d 4 u tet- Street Number I Street Name <br /> CITY - j STATE ZIP _ <br /> f _.n.—_ s <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (1)41) 1 Z7 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUSTOR �� <br /> (vim � V CHECK if BILLING ADDRESS <br /> v <br /> BUST S NAME PHONE# <br /> EXT. <br /> / v'D(/ l �c f'Z s c/�-v 2t S G- 273 �( <br /> 1-l2E or MAILINGDDRESS FAX# <br /> �`/0 +n ,,C ,fid ?' (/t� ( ) <br /> CITY Yk--7-- 1-1 STATE C } ZIP 'Z Q <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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all S.�N JOAOIJIN <br /> C'-.wNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: dal--41 BATE: /tl�y � Z ,� <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGE r OTHER AUTHORIZED AGENT ❑ M <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZA'fiON 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 DEPA:JMENT as soon as it is available and at the Same time it is providgd to me or <br /> my representative. p I� <br /> TYPE OF SERVICE REQUESTED: C n 5AA— 6'I o,) <br /> WMENTS: S,141 <br /> VO e9 <br /> hFq�h►�90���'c Zp�s <br /> SFA FNTOUN <br /> gV44 �l- <br /> F <br /> ACCEPTED BY: EMPLOYEE#: DA1E: <br /> ASSIGNED TO: ^ EMPLGYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: LI I O / <br /> Fee Amount: , Amount Paid Payment Date <br /> Payment TyP#AY1Wf:Ar Invoice Check# Received By: _ <br /> RECEWED <br /> I <br /> EHD 48-0 ;I 7.2015 SR FORM(Golden Rod) <br /> _ 07/17/08 "N JOAQUIN COUWYJ <br /> Eh"kohlg <br /> HEALTH . RTMENT <br />