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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#tet p SERVICE REQUEST# <br /> M <br /> 1 I'fW�O(D-J / S900 o <br /> / OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> j rtGN � " <br /> FACILITY NAME <br /> SITE ADDRESS S G Off//.[ U S <br /> I �Ve—te er Direction 5 ree' t Namnn, � ZIP o a <br /> HOME or MAILING ADDRESS (If Different from Site Address) / {� <br /> �Q ) Street Number Street Name <br /> CITY STATE ZIP <br /> O r ZG <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> (zip 0^ <br /> PHONE 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORL/ ^ a CHECK If BILLING ADDRESS❑ <br /> / BUSINESS NAME /+ PHON # EXT. <br /> S 2D� 3o -OIPI"1 <br /> HOME.or MAILING ADDRESSr. FAII# <br /> zo 2 r GA t ) <br /> STATE ZIP rj <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorlZed 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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY Proof of aUfhor/zatlon 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. EW <br /> TYPE OF SERVICE REQUESTED: Tbw VeINA ✓IIS OVI <br /> COMMENTS: <br /> in ew UEU 21 2016 <br /> EVAOUIIN ROMENO� TY <br /> N <br /> HEA►-TH DEPARTMENT <br /> ACCEPTED BY: VV 't/Uful', V EMPLOYEE III: DATE: <br /> AsSIGNEDTO: MO <br /> V6 O Z I <br /> EMPLOYEE#: DATE: 1-212-7 1 <br /> Date Service Completed (if already completed): 77] SERVICE CODE: ae P/E: <br /> Fee Amount: ( Amount Paid (3 c9 �� Payment Date <br /> Payment Type �' Invoice# Check# Received By:7 <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />