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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �00227al3 500-74`M <br /> OWNER I OPERATO <br /> /') CHECK If BILLING ADDRESS® <br /> FA ILITY NAME u(� r 3 19 P <br /> SITE ADDRESS^_,{Of V1 c ` ` yl � J 5 06 k. o� <br /> U,l Street Number Direction `t Street Name CI ZI Code <br /> HOME Or MAILIN DORESS (If Different from S'a Address / <br /> o 'f.QQ Street Number Street Name 0 <br /> CITY - STATE ZIP <br /> PHONE#1 - ExT' APN# LAND USE APPLICATION# <br /> a,k) 8qgL <br /> PHONE#2 T BOS DISTRICT LOCATION CODE <br /> ( I <br /> f CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> W <br /> A r l/, CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E^T' <br /> ft S J� <br /> HOME Or MAILIN ADDRESS ( - FAX It Age 66 <br /> (� T4- r <br /> ITY 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 1 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 /> APPLICANT'S SIGNATURE: CAW - DATE: <br /> PROPERTY/BUSINESS OWNER El OPER TORI 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 provld ed t0 me or <br /> my representative. 1/ pp �c/��/ <br /> 11 <br /> TYPE OF SERVICE REQUESTED: rJD vm(lfe 1VPn <br /> COMMENTS: <br /> MAY 0-4 2016 <br /> SAN JOAQUIN C <br /> ilEq TNp�AR A Nr <br /> ACCEPTED BY: EMPLOYEE#: - DATE: 51gllp <br /> ASSIGNED TO: (� Dhlf 2 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): - L-- SERVICE CODE: - y�b�l PIE: fLfi'1 <br /> Fee Amount: Amount Paiq( 30 D V Payment Date - / 1lVVJ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />