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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> \. UI /e- <br /> S <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME NO rl Ce'/ S �/ <br /> SITEADDRESS �' odi 1 5 J <br /> Street Number Dlrec(lon " S\reet NaCI L.yt Zio CodOo <br /> HOME Or MAILING ADDRESS (If Di//ff��erent from Site Address) <br /> 4'^ I yl Street Number Street Name <br /> CITY STATE 9. <br /> IP <br /> c ,9215 - <br /> PHONEHI EXT' APN# LAND USE APPLICATION# <br /> w9) LU-DI 69, 1 0y52R��� <br /> PHONE#2 n ExT. BOS DISTRIc LOCATION CODE <br /> L - 26. 1 Oce 02 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE N ExT. <br /> HOME or MAILING ADDRESS FAx tt <br /> ( ) <br /> CITY 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 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. n / <br /> APPLICANT'S SIGNATUR"e. DATE: G —/ 3 f <br /> PROPERTY/BUSINESS OWNER❑ TOR/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, 1, 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 a5 It Is aVallable and at the same time It Is provided t0 me Or <br /> my representative. �/ <br /> TYPE OF SERVICE REQUESTED: Fm f VU4 pA` <br /> COMMENTS: R <br /> " FEB 13 2015 <br /> SA rr PtU111111 � <br /> HEAL(14 DEPA / <br /> ACCEPTED BY: L�fl'V� EMPLOYEE#: DATE: ZJ fJ <br /> ASSIGNED TO: 'e(yppyCtif/ EMPLOYEE#: DATE: T <br /> Date Service Completed (if already completed): SERVICE CODE: w PIE: t�b/ <br /> Fee Amount: Amount Paid '� Payment Date / 13 l� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />