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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 16'2-7 <br /> OWNER/OPERATOR m hon I CHECK if BILLING Ar)DRESS <br /> FACILITY NAME VU( '^ M d[o <br /> SITE ADDRESS ►t A( I � � ' S� <br /> tree[Number Direction traet Name Git_;_ Zi^Codc <br /> HOME or MAILING ADDRESS (If Different from Site Address) ( � <br /> S �'m�p ari co 7`T <br /> tStreet Name <br /> CITY STATE C4 <br /> 1 ZIP (q <br /> PHO N #1 EXT, APN# LAND USE APPLIC.4TION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> f ) <br /> CONTRACTOR/ SERVICE REQUESTOR - <br /> REQUESTOR <br /> Phc)r) CHECK if BILLINI ADDRESS <br /> BUSINESS NAME `^� r— �� P A(dE ` ��• �w Qr� <br /> H M or M ING DDRESS V ') FAx#J <br /> CITYc-�t")1/ $TATE ZIP <br /> BILLING�ACKNOWLEDGEMENT: i, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TATE an FEDERAL laws. <br /> APPLICANT'$SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 /> 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: PAYMENT <br /> COMMENTS: s <br /> EIVED <br /> SEP'2 0 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 24\C—CL-IJ <br /> EMPLOYEE#: Pe—lc�� DATE: (r <br /> ASSIGNED TO: Com` -\ EMPLOYEE#: V � L�,_l Lo/,j DATr: 9 Jap <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: � -L- <br /> Fee <br /> Fee Amount: V76eU Amount Paid 7 g n v Payment Date S vkis <br /> 7 <br /> Payment Type C. Invoice# Check# Received'B <br /> C y �a <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />