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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER I OPERATOR P-°b b 10 SP--66 a I Do o <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME o CCC <br /> SITE ADDRESS J(1� , {//�3f/ y/�%� (//9/// <br /> Street Number fr�ctiont ` d'-1, 1Wretf Nh t0 �� 1DCI �1L <br /> E. <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#1 EXT. APN# <br /> LAND USE APPLICATION# <br /> 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // <br /> CHECK If BILLING ADDRESS O <br /> BUSINESS NAME /� PHONE# EXT <br /> / <br /> f <br /> HOME Of MAILING ADDRESS FAX# <br /> 7 SExC� �l� 1�0 s1�r, <br /> CITY 0 _", STATE / zip <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 DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 /> APP'LICANT'S SIGNATURE: � DATE: lQ_Z GJ—J� <br /> PROPERTY 1 BUSINESS OWNER❑ PF-RATOR f MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization f0 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 i5 provided to me Or <br /> my representative, yrily,�8� I <br /> TYPE OF SERVICE REQUESTED: d Q a l� •yf +1i <br /> COMMENTS: & IC0 <br /> Ma nQ P, 4 (r�Yl SAIV OCT 19 2016 <br /> JOAFNVI C011y C a <br /> HFALrH I)O�Br� lvfY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: F—Ay-yll <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Pa'Id� 1 � (] Payment Date / 'ih <br /> Payment Type r/ Invoice# Check# 7 Received By:��� 1 <br /> END 48-02-025 SR FORM(Golden Rod) <br /> 0711710E <br />