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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTH L �,-ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#� <br /> .o a �E2 ec,J �K. 06 -78070 <br /> OWNER I OPERATOR <br /> y� C � CHECK If BILLING ADDRESS <br /> E] <br /> ^ � <br /> FACII'-".kl—' lA <br /> n qs <br /> SITE ADDRESS <br /> 3 _ Set Name Z'aICOotleStreetNumber cctS <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> p 3 K Ise&167- S Street Number Street Name <br /> CITY STATE ZIP <br /> 4ktir r-/-x qSa �Y <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> L209) ')I S S 8 2 1 <br /> PHONE#2 EXT. BOB DISTRIICCT LOCATION CODE <br /> o <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> `C1 �d'-J CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Lo 2w o nJ vi J o 71 5- B 5 :3 <br /> HOME or MAILING ADDRESS FAX# <br /> to 'it3e-e (ert S ( ) <br /> CITY S 0C 'S STATE CA zip 9 Sao <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,STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �. DATE: to g- / <br /> PROPERTY I BUSINESS OWNER El 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the Same(i�ne it is provided to me or <br /> my representative. /mac j. <br /> TYPE OF SERVICE REQUESTED: �Fj FIC <br /> COMMENTS: OST1 <br /> ! � SAN 8 2017 <br /> U ei F 9' SAN <br /> OUN1Y <br /> 1 HOFPgR At <br /> ACCEPTED BY: EMPLOYEE#: DATE: i Jr �G /7 <br /> ASSIGNED TO:-r 16 G EMPLOYEE#: DATE: /VO - / — <br /> Date Service Completed (if already Completed): - SERVICE CODE: S Z—<�:> 11 P/ 0 <br /> Fee Amount: t..4 *� Amount Pat v� Payment Date 7� �o <br /> Payment Type�� �_ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />