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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UmPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERu,IGFJ?EaUc�L- <br /> f <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME N ✓1 <br /> SITE ADDRESS 8 Grk N t^ -ftUC*T0 IJ <br /> Street Number Direction Street Nnme Ci.• :^ "l./ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> q0 -ZV 1 1 Street Number Street Name <br /> CITY STATE ZIP <br /> L IcTo C <br /> PHONE#1LAND USE APPLICATION# <br /> ( 4) q>{q - a06-677777N# <br /> uaa . ExT. APN# <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUEST'€ R <br /> REQUESTOR /��• <br /> �9e—P' \��N CHECK If BILLING ADDRESS <br /> BUSINESS NAME ��/.�..r/�1 `` PHONE# EZT. <br /> L�p�'r" YII� tG 224 ) <br /> HOME or MAILING ADDRESS _ FAs# <br /> CITY �10r ` STATE 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 thi appli and that th o to will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard _STAT 'nd ED L la s <br /> APPLICANT'S SIGNATURE: DATE: �q -�GI aOI <br /> ROPERTY/BUSINESS OWNER❑ OR/ ANA ER DTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING 00 fauthorization 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 time It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Min <br /> COMMENTS: LI <br /> SEP 3 0 2016 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: C? <br /> Date Service Completed (if already completed): SERVICE CODE: 6 60 P1 E: <br /> Fee Amount: , Amount Paid Z Payment Date 01 . 3 (-) . <br /> J U , l� <br /> Payment Type C� Invoice# ✓ Check# Received By:' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />